 So the title of this discussion is Orthopedic Issues in Women Today. I picked three topics. There are a few others that we could discuss and feel free to ask questions along the way or in the chat, but the issues I picked to discuss were anterior cruciate ligament injuries, adhesive capsillitis of the shoulder, and osteoporosis and fragility fractures. I picked these because they do specifically affect women in different ways than they do men, and each of these tends to happen in a specific timeframe in a woman's life. The ACL being in the younger years, the adhesive capsillitis in the middle age years and osteoporosis and fragility fractures as we get older. ACL injuries, as many here may know, are a serious knee injury that we see in mostly teenagers and young women in their 20s up into their 30s. We don't see them as frequently as we get into our middle age and older, probably really because we're not playing the same sports and participating in the same activities that we were when we were younger. It's a serious knee injury, mostly in athletes, tend to see this in pivoting field and jumping sports. Some people are not aware that about 70% of these injuries are non-contact injuries. It's a pivoting maneuver or a jump landing maneuver. Nobody contacts the athlete. There's no collision. The majority of the time it's a one-person injury or the ligament ruptures. This is typically season ending. It can be career ending depending on where the athlete is in their career. Most of the time it requires surgery and a pretty long rehab, six plus months of therapy before the athlete can return to play, sometimes more like 10 months or so. One of the reasons I picked this topic was because it is important for people to know that this is much, much more common in women. Up to a five to one ratio, perhaps even up to six or seven to one ratio in some studies. I'll get into some of the reasoning that we think of why that happens in just a minute. A little anatomy review here. The ACL is a ligament in the middle of the knee as you see here in this schematic at the top of the slide. A ligament that goes from the femur to the tibia connects those two bones and when it ruptures tends to rupture right in the middle. This lower left photo is a cadaveric dissection. We're looking at a side view of the knee in the center of the knee. This is the ligament here going from femur to tibia. It's this structure here. It's not all that big a structure when you think about it, but it's an important one. We do typically obtain an MRI when we suspect this has been injured. And in this MRI on the left, this is a normal MRI. The ACL is this ligament going from the back of the femur to the front of the tibia, this dark structure here. To our right that in that ligament has been injured. It's not in the proper orientation you can sort of see it here, but it's been torn off the femur. If you were to look inside that knee arthroscopically, this is what you would see on the right side. This is the ligament which has been ruptured. It looks like a torn shoelace, if you will. Most commonly we will reconstruct these. So for the most part you can't repair that ligament, although there is some newer methodology that tries to repair the ACL. But for the most part we are reconstructing it and putting a new ligament inside the knee arthroscopically. So these are cameras looking inside the knee and a new ligament is put in the center of the knee through tunnels and screws are placed through the bone to hold that ligament in place. So as we were talking about issues in women, orthopedic issues in women today, why does this happen? So what are the risk factors? Well female gender is definitely a risk factor. A prior ACL injury is a risk factor for re-injuring your ACL or injuring the other knee. Family history goes along those lines as well. There is a genetic component to this. But as we get into perhaps the reasoning why this is more common in women, women have smaller ACLs and the smaller your ACL is, the higher the chance of it rupturing. Ligament is laxity is a risk factor. What that means is people who are really flexible, double jointed, if you will, or just have really loose joints, that is a risk factor and that is more common in women than it is in young men. One of the more important factors, risk factors is the hip knee ankle alignment. You can sort of see that in this schematic diagram on the right. This patient is pivoting and women tend to have wider hips than men. So the wider hip with a knocked knee alignment and the ankle pivoting out is a position of risk. So women tend to assume this position more commonly than men do in certain athletic events. What about the hormonal cycle? That's been studied and there is some literature out there to support contribution of the hormonal cycle. Perhaps the follicular phase of the menstrual cycle plays a role, but that has not been fully elucidated. I can't say if that's true when these occur, which part of the cycle and along those lines can hormonal treatments or contraceptive medications prevent an ACL disruption that has been studied but without conclusive evidence. Back to the alignment theory though jumping mechanics matters and especially in sports like volleyball and basketball and women. Men help teach athletes a more athletic jump landing technique. So this picture here shows what you might call an athletic jump landing technique. On the left, the patient's landing with both knees sort of boxed squared out with of the shoulders ready to jump again compared to on the right where the knees are knocked together. The knees are not quite even. They're twisting inwards that's a position of risk and that's one that you worry that that person's going to injure their ACL. So with that in mind, can you prevent an ACL injury. And the answer is yes, maybe we can. There are studies to show that if we involve athletes, especially athletes at risk people have torn one ACL and are and are going back to their sport. So it's not just for tearing the other ACL or the original ACL, or perhaps the whole women's volleyball team at a certain school may want to participate in an injury prevention program. This has been shown to help improve jump landing and pivoting mechanics, and several studies have shown decreased injury rates in ask at risk populations. So that's one thing we can do to to help prevent these sometimes devastating injuries. So that's it for ACL injuries. If you if you have a question that you want to enter into the chat. You can do that now. And then we can get to that to resume we have our discussion. I'll just give that a minute and then I'm going to move on to the next topic of the three. So switching joints here before we were talking about the knee and the ACL now we're talking about adhesive capsillitis you might not have heard that term before. That's a term specifically to the shoulder. It's describing a condition that happens to middle aged women. Yes, it can happen to men, but it's very uncommon in men's happens in in women in the 40s to 60s. We don't tend to see it in someone in their 20s or 30s and rarely in 70s or 80s. Another term for this is frozen shoulder, although that sometimes an overused term, but it is, for the most part, one in the same. What happens here is the body for unclear reasons. It produces an inflammatory response around the shoulder, and it and the shoulder becomes very painful, and eventually becomes very stiff. So it's pain, followed by stiffness. This shoulder will be painful with activity but also at rest just sitting there in a chair you have a painful shoulder, and it will be very painful at night and difficult to sleep. I just started to mention there's typically no known cause or traumatic event. So it's referred to as idiopathic we're not quite sure why it happens, but I do believe it has an autoimmune component that is temporary this does go away, although it takes a while. So there's some confusion early on patient has a painful shoulder maybe there was a very minor trauma that that so led them or their practitioner to believe that they may have a rotator cuff tear where they have impingement syndrome or bursitis around the shoulder. It's easy to confuse these early on, but as this this process evolves it becomes more apparent. I mentioned risk factors female gender is definitely a risk factor and being Middle Asia's a risk factor. We also see this more commonly in people with diabetes as well as thyroid disease, which is interesting to me, because those are both autoimmune disorders and typically if you suffer from one autoimmune disorder you may be at risk for developing another one. As I mentioned, I do believe there's an autoimmune component to adhesive capsulitis. As I mentioned trauma sometimes trauma can initiate this. And in fact there is a post traumatic frozen shoulder, where a bad injury happens a bad fracture or a big surgery, and the patient ends up with a stiff shoulder. That's a known entity, but really for the intense of this, this talk, we're really talking about this idiopathic adhesive capsulitis that happens with little or no trauma. It shows the deepest layer of the shoulder before you get down to the joint this is the capsule, and it's read it's inflamed it's getting scarred down and it's going to get tight. So how do we diagnose this condition well, like many things in orthopedics, or in medicine in general I would say the history is the most important part, certainly with this condition, the history of insidious onset of pain. It doesn't have nowhere. It develops relatively slowly over the course of weeks or month on the pain progressively gets worse and worse and that's typically what brings the patient to the doctor. Eventually it becomes stiff but most commonly the patient is coming to you before it's actually starting to get stiff, because it hurts. The patient's arm is defined by painful, active and passive range of motion. So when I move the patient's shoulder that's passive range of motion it's painful and it's stiff, and when they move their shoulders painful and stiff. Interestingly, when I diagnose this, I do check all planes meaning I check the, the elevation I check the rotation I check the extension, and in adhesive capsulitis, everything gets stiff, not just one particular plane like we might see in conditions such as impingement syndrome or bursitis. And importantly, strength is intact. So if someone has a bad rotator cuff tear or a bad injury to the shoulder their strength will not be intact they cannot resist a force on their shoulder. But with adhesive capsulitis, they can it hurts, but if they give a good effort, I can test their shoulders see the strength and, and to some degree prove that their strength is intact the rotator cuffs intact. So the issue, the issue is the painful and inflamed capsule. With this particular diagnosis, additional tests such as an MRI or CAT scan really aren't that helpful they don't show very much. You can theoretically rule out other conditions but with it as with really any tests, you have to be a little careful with that because if that test is not 100% normal. That would be at a 50 year old patient probably, you wouldn't expect that there's going to be some changes, and that can cloud the picture so MRIs are not typically helpful with this condition. So management, how do we treat this. Unfortunately, there isn't a great treatment for this, but it does require a close follow up with the patient to ensure that they're getting along okay and they're managing through what is a difficult time, because this condition does get better, but it takes time, it gets better on its own, but it takes time, we can help it along with certain things physical therapy is important. I did put some asterisks here because I wanted to remind myself to tell you that physical therapy is important but it has to be with the right diagnosis if this is misdiagnosed. And someone is going to therapy for a rotator cuff problem or a tendon problem. They may be doing some strengthening exercises to strengthen that rotator cuff. And, and those were just going to inflame the shoulder more the therapy needs to focus on stretching and passive range of motion sort of like you see in this picture here. To help maximize range of motion as the patients getting through this process. Medications do help over the counter medications typically anti-inflammatories. Cortisone injections can help but unfortunately they don't fix the problem and they tend to be short lived so we don't always do them in these patients. The therapy is rarely indicated, but once in a while that's necessary to release that scarred down capsule, and to improve the range of motion with a manipulation. I mentioned time. Time is the best treatment for this condition. The patient has to get through the three phases of adhesive capsulitis. The three phases of a frozen shoulder which are the freezing phase the frozen phase, and what we call the thought. The first phase is the most difficult it is painful, and it seems like it's never going to get better it's only getting worse. When it started when it started when it's frozen it's actually stiff at that point. It's locked up and the patient really can't move it that well but they almost don't even care because the pain has started to improve once it has started to really freeze. And then it falls out over time. It loosens up therapy helps and then they get their motion back. And then they get rid of this disease, but sometimes it won't free up on its own, and it just never really progresses to the proper phases. So we have to look inside the shoulder and do a surgery and this would be maybe one out of 20 people I see with a frozen shoulder do I end up actually doing a surgery on. This is here show an arthroscopic view of the shoulders so you're looking in the shoulder from the back to the front. This would be the front of the shoulder. And this is a normal tendon that's your sub scapularis tendon with capsule on top of it. And this is the cartilage here on the right side you really can't see all that all you see is red if you ask me that is a red angry inflamed scar down capsule. And this is very painful to me, we can help that by releasing that tissue in the operating room and then getting the patient into therapy from there. So that's frozen shoulder adhesive capsule is I expect there might be some questions about that happy to answer those after we get through our next topic which is excuse me one second. I think we've all probably heard of that I hope you have because an important topic to remember. It's a silent disease doesn't hurt. But it's affecting many people if not most people as they get into their 5060 70s and older. What is osteoporosis osteoporosis is the age related loss of bone mass. The results in weaker bones which are at a higher risk for a low energy fracture what we sometimes call a fragility fracture. Most people think of the hip when we talk about osteoporotic fractures, but many bones are at risk and the common ones that are involved in injuries are the wrist, the shoulder, as well as the spine which which can suffer from compression fractures. It's different than osteoarthritis I did consider putting osteoarthritis in this talk, as it is equally common and a very common reason to be coming to the orthopedist office. I wouldn't say it's gender specific, but osteoarthritis and osteoporosis are sometimes confused osteoarthritis is the degeneration of the cartilage in a joint, perhaps most commonly the knee. It doesn't even tear it starts to break down it's painful it's stiff and and it may eventually need something like a knee replacement. We do a lot of other things for osteoarthritis so things such as injections and physical therapy and medications which can all help not to be confused with osteoporosis which is not painful until there is a broken bone. The comment is probably all too common 54 million Americans suffer from osteoporosis. There is one fracture every three seconds in our country related to osteoporosis. One in three women will suffer an osteoporotic fracture, and that's way too high. It's not very scary statistic, but it's worth reading and remembering. There's a 30% mortality rate, the first year after hip fracture, meaning if grandma falls down breaks her hip. We get her up and walking as soon as we can. But that fracture is sometimes a sign of a greater disease process, other health issues deteriorating health, and an aging life, and that patient is at risk of not being with us 12 months later. These are patients who really are at the end of life. But other times, this can be the beginning of a downward spiral that if we could prevent that hip fracture, we could extend life. This is what it looks like. If you look at this picture, the hip on the left is a normal hip. It has a strong outer layer. The inside layer looks a little bit like coral might look. It is porous, but not nearly as porous as the bone with osteoporosis, which has less bone and bigger cavities within the bone. That's a weaker bone that's at higher risk for fracture. So what are the risk factors for osteoporosis? Well, female gender is early menopause is a risk factor. Diabetes and other endocrine abnormalities play a role. The skeletal system is part of our endocrine system. It is a dynamic system that's constantly changing. It is not a static system. It's affected by what we do, what we eat, the medicines we take, and it's part of the endocrine system. Smoking affects bone health just like it affects about everything else. Here's an important one, the medicines we take. So oral or IV steroids, if you're on oral steroids, IV steroids for a significant period of time, say because of chronic asthma or COPD, these can be a couple of reasons that weakens your bones. In addition, I didn't write it down here, but whoops, seizure medicines. If you have a seizure disorder, that too can lead to weaker bones. In addition, our stature and our race matter. So thin white women, thin Asian emails are at higher risk for osteoporosis than some of their peers. Unfortunately, we have to fix these fractures often. They're very common these fractures. We seem to get probably one a day at the bigger hospitals. When you break a hip, you can break it in different places around the hip and that can require different types of treatment, whether it's pins or a plate and screws or a rod or a partial hip replacement or a total hip replacement. We do all these things depending on the patient and depending on the pattern of the fracture. But as I mentioned, it's not just the hip. The wrist is frequently involved. The spine gets involved and this can be a bit more of a silent fracture in that maybe someone has a backache, a sore back, maybe they didn't fall. They started having some back pain for a while. They noticed their posture was changing. They noticed they've shrunk a little bit over time. That can all be from compression fractures in the spine related to osteoporosis. Right. This is a picture of a shoulder. This is a broken shoulder, which commonly breaks when people land on the shoulder with osteoporosis. So what can we do about it? Is an osteoporosis just part of normal aging? We get weaker as we get older. Our bones get weaker. Yes and no. That's a theoretical argument, I suppose, but it doesn't have to be that way. We can help prevent fractures and we can help prevent falls with exercise. Exercising, as we all know, is important for our overall health, our heart health, our weight. And it's also important for our skeletal health. If we exercise regularly, we have stronger bones, we have stronger muscles, we have better balance, we're less likely to fall. And if we do fall, it may be a more coordinated fall rather than an unprotected fall where the patient just keels over and lands on their hip and breaks the bone without really being able to protect himself on the way down. So, if any of us are thinking about getting back into an exercise routine, start now. No better time than the present. And indeed, there are studies that show that in New York City, there was a Tai Chi class that a senior population participated in and they had fewer falls and when they did fall they had fewer fractures. And smoking cessation once again is a good idea helps decrease fragility fractures and osteoporosis. Our diet does matter a well balanced diet is important. The old story of the old couple eating tea and toast every day is not good enough that's a setup for osteoporosis. We do need calcium in our diet we need vitamin D vitamin D supplementation is probably a good idea at this latitude in our planet. It matters and we don't get enough of it so vitamin D supplementation is definitely something to consider protein probably matters as well. You should get a bone density test if you are a female over the age of 65. You should get that every couple of years to monitor your bone density. I put an asterisk next that 65 because if you have risk factors, such as being on steroids for a long period of time or having early menopause for any reason, and perhaps a bone density test at an earlier age is appropriate for you. And if you do have osteoporosis, you should strongly consider the medications that we have available to us to help improve your bone health. No amount of calcium or vitamin D is going to reverse osteoporosis, but the medications can and they do help prevent additional fractures. They do have side effects, and some people are afraid of taking these medications be cause of the side effects that they too often hear about. But I'd like to just let everyone know that those side effects are rare and hip fractures and other fractures are not rare and they're not fun and they can be the beginning of a bad downward spiral. So if you can consider taking the osteoporosis medications when they're recommended to you. That is really something to strongly consider. So that's, that's the end of my topics listed here but I'm happy to discuss any questions regarding what I just mentioned or any other women's health issues. Dr. Swan, I'll kick it off with a question of my own. Okay, I've been a, I've been a bit of a clutch throughout my life and I've broken many bones. Does that make me more susceptible to osteoarthritis or osteoporosis. Yes, and no. So having broken bones before if you've damaged a joint say you had a fracture that went into your knee, or one that went into your wrist like through into the joint itself. That puts you at higher risk for arthritis. We might call that post traumatic arthritis, but having fractures before does not increase your risk of osteoporosis. Great. Thank you. We have a question that came in. Can you talk about osteoporosis treatments and effect on dental health. Yes, that's a good question. So there, the medications for osteoporosis. You've, you've heard a lot of them you've probably seen some commercials for them. Fosamax was a big one many years ago, Boniva. There's several, several other specifically referred to as bisphosphonates. And then there's also Fortale, which is a different category that we use in more severe cases, but the bisphosphonates things like Boniva, Prolia are good medications that help increase bone density. They do this by inhibiting the normal resorption of bone. The cells are called osteoclasts and they can inhibit those to allow bone to build up more over the years. However, your question about dental health. When, when people take high doses of these medications, a small percentage of people can develop osteonecrosis of the jaw, which is a significant problem in the jaw and can make it difficult for the dentist and the periodontist to do tooth implants and major reconstructive surgery around the jaw. However, the vast majority of those cases that have occurred occurred in people who were taking these medications not for osteoporosis, but for diseases like multiple myeloma and other cancers of the bone. So it's definitely a potential problem and it's more so a problem if you're taking really high doses of these medications, but it's very rare. It's not nearly as common as the dentist and the oral surgeons fear that it is. Thank you. We had another question come in. Okay, for a patient where a patient diagnosed is needing a knee replacement based on an x-ray. Would you recommend also getting an MRI first? No. We tend to diagnose arthritis with x-rays. You can see it on MRIs, but you actually see arthritis probably best on our x-rays. That's how we really determine the severity of the arthritis. If it's bad enough on an x-ray, for someone to suggest a knee replacement, the MRI is not going to be of any value. It will say the same thing. Having said that, people often want an MRI because they want to know what their meniscus looks like or their ligament looks like, and maybe those are causing their pain and not the arthritis. The reality is when you have anything from moderate to severe arthritis, meaning the cartilage has broken down and the joint has worn out, it sort of is irrelevant what the meniscus or the ligaments look like because the real problem is it's a worn out joint that needs replacing. Great. That's the last question we had in our Q&A. Does anyone else want to ask a question at this time? Anyone ever had a frozen shoulder? We do have another question that just popped in. Not about frozen shoulder though. They wanted to know arthritis is common in women in their 30s. So the answer there is no, not really. But when we talk about arthritis, there's more than one type of arthritis. By far the most common is osteoarthritis where the joint is wearing out and that happens to people in their most commonly 50s, 60s, 70s, sometimes 40s. I wouldn't expect to see that in someone in their 30s. There's post-traumatic arthritis, which we briefly mentioned, and that's if you've had a bad injury to that joint, like a fracture, then you potentially can, the joint has been badly damaged and it wears out more quickly at a younger age, but that's not that common. There's a whole other category of arthritis types, and that includes the autoimmune disorders such as rheumatoid arthritis, psoriatic arthritis, lupus-related arthritis, all these autoimmune diseases, and those do affect people in their 30s or even younger, as young as their teens, and can be very destructive. They're not that common, and typically people know that they have that autoimmune disease, and it's not affecting just one joint. It's affecting more joints than just, like, say, Aneed. Another question came in. Can you comment on the effects of long-term, two to three years, high-dose steroids on bone and muscle health? Yes, so you never know exactly who that's going to affect, but long-term, especially medium to high-dose, oral or IV steroids, can have a profound effect on the skeleton. It definitely is a risk factor for osteoporosis, meaning weakening of the bones. In addition, other things can be affected. There's a condition called avascular necrosis, typically seen in the hips, sometimes the knees, sometimes the shoulders, where the bone and cartilage deteriorates somewhat rapidly and can be very disabling. Steroids are a great tool in medicine, but they have a lot of side effects, and if we don't need to be on them chronically, then we'd rather not be on them, or at least not at a high dose. Another question for you. Is bone density the only way of diagnosing osteoporosis? That's the most common way we do it. Yes, theoretically a bone biopsy could help diagnose that, but that's not typically how we do it, but a pathologist might comment on osteoporosis if someone's had a bone biopsy for other reasons. In addition, in the operating room, when we're fixing a fracture, we can get a general sense that, hey, this is really weak bone, this is porous bone, but you can't grade it that way. You grade it on a scale based on a DEXA scan or bone density test. Having said that, X-rays and CAT scans do show advanced osteoporosis, but it has to be pretty advanced to see it on an X-ray. Thank you. See if there's any other questions. I saw Kaylin Harper wanted to know what a frozen shoulder was. Oh, there's a couple more questions there. So frozen shoulder. I'll just review that one real quick since there's a question. That's a condition without any trauma where the body sort of attacks the shoulder causes a great deal of inflammation and eventually scarring of the deep layer, the capsule around the shoulder. It's painful, and then it becomes very stiff. And it's the sort of thing that does get better on its own, but it takes a while. I see a couple more questions here. What can I do to keep my bones healthy? So some of the things I discussed earlier was exercise is definitely important, weight-bearing exercise. Although swimming is a great exercise, that one's not actually that good for your skeleton because it's not weight-bearing. So we need weight-bearing exercise, whether it's aerobics or running or working out in the gym. Those are all good for your skeleton. Not smoking is important. Smoking does weaken the skeleton. And then diet does matter. Having a, as usual, a well-balanced, well-rounded diet with adequate calcium and vitamin D is important to keep your bones healthy. What's the right amount of calcium you should have in your diet if you're taking it in pill form? It's pretty controversial, and it's always going up and down. Sometimes the cardiologists get concerned that it may play a role in the calcium deposits we see in the coronary arteries. Others have said that that's not correct, so that's not an actual, it shouldn't be an actual concern. I try and simplify everything. If you took a thousand milligrams of calcium and a thousand units of vitamin D per day, that's a pretty good baseline right there. That's within a safe range, but also a good baseline to give you some foundation.