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In Motion January 2012

Osteoporosis: Fact vs. Fiction

By Johnny Su, MD

Osteoporosis is a disease that weakens bones, making them more susceptible to sudden and unexpected fractures. Literally meaning "porous bone," it results in an increased loss of bone mass and strength. It’s also quite common, affecting more than 10 million Americans, with another 34 million at risk due to low bone mass.

In fact, about 40 to 50 percent of women over 50 – and 33 percent of men over 50 – will suffer an osteoporosis-related fracture in their lifetime. One way to help reduce your risk is to understand some common misconceptions about the disease. Can you tell fact from fiction?

1. I’m too young to worry about osteoporosis. Only older adults get it.

False. Although osteoporosis is more common in older adults, anyone can be at risk for this disease. Technically, osteoporosis can only be diagnosed in older adults due to presence of a fragility fracture after the age of 45 or on the basis of a bone density scanning test – called DXA, using a T-score in peri or post-menopausal woman and in men over the age of 50. However, anyone can have low bone mass for their gender, age and ethnicity which can lead to fractures. This can be determined on the basis of DXA using a Z-score.

Factors that increase the risk of weak bones include medical conditions, such as vitamin D deficiency, hyperthyroidism, rheumatoid arthritis and inflammatory bowel disease. Medications (such as steroids and proton pump inhibitors), behaviors (such as tobacco use and excessive alcohol use), and family history of osteoporosis also increase risk. Healthy habits, such as adequate calcium and vitamin D intake and exercise, can help prevent weak bones by making sure that a person achieves peak bone mass.

2. Now that I’ve been diagnosed with osteoporosis, I have to cut back on my exercise routine.

False. Exercise is actually an important part of the treatment regimen for osteoporosis. Weight bearing exercise, such as walking, can in fact help improve bone strength and quality. Combined with strength training using light weights, weight bearing exercise will improve muscle tone, balance and coordination – preventing falls that may result in fractures.

The key fact to remember about exercise is not to avoid it altogether, but rather to be prudent in terms of the type of exercise. Activities such as jumping, running and jogging tend to put more stress on the vertebrae in the spine, predisposing individuals to compression fractures. Likewise, motions that result in bending at the waist or twisting of the torso also put more stress on the vertebrae. In terms of weight lifting, excessive weight also puts undue pressure on the spine, leading to a higher risk of compression fractures. Remember: Keeping up with rather than cutting back on your exercise routine with the proper modifications can help treat osteoporosis by preventing future fractures.

3. Taking calcium supplements causes heart attacks and strokes, which outweighs their benefits in treating osteoporosis.

In April 2011, researchers re-analyzing data from the Women’s Health Initiative reported that taking calcium supplements may increase the risk of cardiovascular events, especially heart attack. However, this does not necessarily mean that individuals taking calcium supplements should stop taking them. Future studies are necessary to determine the risk for specific populations. Therefore, for a person who is at a higher risk for heart disease vs. risk for osteoporosis or fracture, a calcium supplement may not be appropriate.

These recent findings also do not mean that adequate calcium intake is no longer important for bone health. Calcium from food sources provides the same benefits as calcium supplements and does not appear to be associated with increased cardiovascular risk. Getting adequate calcium from the diet is strongly encouraged and calcium supplements should only be used to compensate for inadequate dietary intake.

In terms of elemental calcium requirements, post-menopausal women and men over the age of 65 should get 1,200 to 1,500mg daily; pre-menopausal women and men under the age of 65 should get 1,000 to 1,200mg daily. Excessive calcium intake above these values does not appear to provide additional benefit and may result in increased risk of cardiovascular events and kidney stones.

Dr. Su is a Cleveland Clinic rheumatologist who specializes in osteoporosis. He sees patients at main campus, Twinsburg Family Health Center and Ashtabula County Medical Center.

To make an appointment with Dr. Su or any of our rheumatologists who specialize in osteoporosis, please call 440.312.6242.

Aching Knee? Try Acupuncture for Relief

By Jamie Starkey, LAc

“Can you help me with my knee pain?" This is often a question I’m asked when someone discovers I’m an acupuncturist. Knee pain is a common and often debilitating condition that affects people of all ages.

Knee pain can be caused by several different factors including injury and arthritis, which also can cause stiffness and decreased range in motion – ultimately affecting your mobility and quality of life. Despite conventional treatment options (such as medication, surgery and physical therapy) patients can sometimes still suffer from knee pain. Luckily, there is another option that can be explored: acupuncture.

Acupuncture is a branch of Traditional Chinese Medicine (TCM) with a rich history and lineage dating back thousands of years to ancient China. In acupuncture, an acupuncturist inserts hair-thin needles into the body to promote a pain-relieving effect. This process is truly a medical art, as each clinician uses various approaches, techniques and styles to address knee pain; no two patients are treated the same.

Conventional medicine has begun paying closer attention to acupuncture. The American College of Rheumatology (ACR) addresses acupuncture in their recommended clinical practice guidelines as a non-drug treatment option under investigation. There have been numerous clinical studies supporting the pain-relieving effect of acupuncture on knee pain. Research shows acupuncture releases endogenous opioid endorphins – the body’s natural pain relieving chemicals. In addition to decreasing pain, acupuncture also is found to increase range of motion of the knee joint and decrease joint stiffness.

Acupuncture is now available in many U.S. hospitals and at private accupuncturists’ offices. No matter which you choose, your initial appointment with an acupuncturist will usually be the longest visit as you undergo a detailed assessment from which an appropriate treatment plan is developed.

For patients who are knee pain sufferers, oftentimes a multidisciplinary approach is optimal. Acupuncture can easily be incorporated into your conventional treatment plan, working in tandem with your physician and rehabilitation specialists. If you are a knee pain sufferer, speak with your provider about integrative treatment options like acupuncture, and you may just find relief!

Jamie Starkey, LAc, is Lead Acupuncturist with Cleveland Clinic’s Center for Integrative Medicine. She sees patients at Cleveland Clinic main campus, Sports Health Center in Garfield Heights and Lyndhurst Campus.

To make an appointment with Jamie or any of our other acupuncturists, please call 216.986.4325.

Help for Tennis and Golfer’s Elbow

By Eric Ricchetti, MD

”Tennis elbow,” or lateral epicondylitis, is a common cause of elbow pain that occurs due to degenerative changes or “wear and tear” in the tendons that attach on the lateral epicondyle, a bony bump on the outside of the elbow. Commonly described as a tendonitis, the condition is actually better called a tendinosis – meaning it is caused by a degenerative process in the tendon rather than an inflammatory condition. Tennis elbow most commonly affects patients 30 to 60 years old and symptoms include chronic pain on the outside of the elbow, on or near the lateral epicondyle. The symptoms are usually aggravated by wrist extension and/or forearm rotation, particularly with repetitive activities that involve these motions. The elbow may be tender to touch over the painful area, and pain can be worsened by movements that stress the involved tendons, such as resisted wrist and finger extension and/or resisted forearm rotation.

In most cases, tennis elbow can be successfully treated without surgery. Treatment is directed at avoiding activities that bring about the symptoms if possible, use of non-steroidal anti-inflammatory (NSAIDs) medication, physical or occupational therapy, elbow or wrist splinting for symptom relief, and cortisone injections at the elbow, if needed. Therapy exercises are focused on both strengthening and stretching the affected muscles and tendons. Splinting can include a wrist splint to place the irritated tendons in a resting position, or a tennis elbow strap to unload the tendons during lifting activities. Cortisone injections can be beneficial if symptoms become more severe. But if given too frequently, these injections can in rare cases cause thinning of the skin and tissues around the elbow and even lead to rupture of the affected tendons in rare cases. Surgery is occasionally needed when other treatments fail to relieve symptoms. The operation is typically an outpatient procedure and involves cutting out or repairing the area of damaged or degenerated tendon tissue to eliminate pain. The surgery is done through a small incision on the outside of the elbow, but arthroscopic techniques are now being used in some instances. A splint is worn after surgery for a week or two, after which the patient can get back to light activities using the arm and stretching exercises for the elbow. Patients can return to most daily activities, except heavy lifting, in four to six weeks after surgery.

“Golfer’s elbow,” or medial epicondylitis, is a condition similar to tennis elbow that occurs on the inside, rather than the outside, of the elbow. As with lateral epicondylitis, the condition involves “wear and tear” in the tendons that attach on the medial epicondyle, a bony bump on the inside of the elbow. Symptoms include chronic pain on or near the medial epicondyle, and are usually aggravated by wrist flexion and/or forearm rotation. A person’s elbow may be tender to touch over the painful area, and the pain can again be made worse by movements that stress the involved tendons. Management of golfer’s elbow is similar to that for tennis elbow, with most patients successfully treated with activity modification, NSAIDs, physical or occupational therapy, elbow or wrist splinting, and cortisone injections at the elbow, if needed. Surgical treatment, if needed, is again aimed at cutting out or repairing the damaged tendon and has a recovery similar to tennis elbow surgery.

Dr. Ricchetti is an orthopaedic surgeon specializing in the elbow and shoulder. He sees patients at Cleveland Clinic's main campus and Cleveland Clinic Orthopaedics, Middleburg Heights.

To make an appointment with any of our elbow experts, please call 440.312.6242.

Not Your Usual Bunion: Understanding Hallux Limitus

By Georgeanne Botek, DPM

Think you have a bunion limiting your choice of footwear? Is your big toe joint pain keeping you from being active? You might actually be suffering from a condition called hallux limitus.

What is hallux limitus?

It is limited motion in the big toe or its joint (called the first metatarsal-phalangeal joint). It’s most severe stage is called hallux rigidus, or when there is essentially no functional motion left in the joint. Although it is sometimes referred to as a “dorsal bunion” due to the presence of spur formation on top of the joint, hallux limitus is not what your physician calls a “bunion” – or literally “turnip.” A true bunion, or hallux valgus (not hallux limitus) is a bump or bone protrusion on the inside of the big toe. Hallux limitus, on the other hand, is a form of osteoarthritis and pain on the top of the foot.

What causes hallux limitus?

This condition is often the result of degenerative arthritis or osteoarthritis. It can also be due to repetitive jamming of the big (or great) toe.

In patients with hallux limitus, there is a decrease in the amount of upward motion (dorsiflexion) of the great toe caused by structural changes or functional abnormalities. Typically, the normal range of motion of the great toe is 65 to 75 degrees. The amount of motion in a person with hallux limitus depends on the degree of degenerative changes in their joint. Pain is ultimately the result of cartilage destruction and bone-on-bone friction inside the joint.

Who is at risk?

Foot shape may play an important role in this condition. A long first ray – which is made up of the great toe, metatarsals (long bones in the foot) and bones back to the ankle bone – may lead to hallux limitus or hallux rigidus. An elevated 1st metatarsal is another common cause.

In athletes, injuries such as turf toe may be the culprit. Finally, it may also be a result of systemic diseases, such as rheumatoid arthritis or gout. More often than not, it is believed that a combination of factors lead to the development of the degenerative changes in the joint.

What are the symptoms?

Patients often relate having a deep aching pain inside or on top of the joint after periods of physical activity. As the condition progresses, patients may experience cracking or popping in the joint with increased pain.

Some patients may experience a burning and tingling sensation. This may to due to nerve irritation in the toe.

Callus formation may be noticed at the bottom or inside of the great toe. This tissue is referred to as a pinch or spin callus, as it is formed by the skin in response to abnormal mechanical pressure.

How is it diagnosed?

You should be evaluated by a foot and ankle specialist. X-rays are often warranted to rule out any other causes for the great toe joint pain and decrease in motion. Findings commonly include a “dorsal flag,” which is a spur formation on the top of the 1st metatarsal bone. The joint will appear narrowed and arthritic, depending on the severity of the condition.

How can it affect my daily activities?

Patients with hallux limitus may compensate and walk abnormally by transferring the weight to the outside of their foot leading to other issues, such as pain and swelling or other leg and joint pain. It is important to maintain a regular exercise routine for a healthy lifestyle. Hallux limitus is a painful condition which can have a negative impact on physical activity and overall health.

How is it treated?

Conservative measures such as stiff-soled shoes, rocker-soled shoes and custom-molded foot orthotics are often recommended to decrease stress in the joint. Anti-inflammatory medications and corticosteroid injections are sometimes helpful with acute pain and inflammation. Ultimately, surgical intervention may be necessary to restore functionality and to regain a pain-free lifestyle. A few patients with arthritic joints may benefit from a cheilectomy, a procedure that removes the spurring of the joint and releases surrounding scar tissue. Physical therapy is often used to decrease pain and stiffness that may occur after surgery. In more severe cases, the joint must be taken out in part, replaced or fused to stop painful motion.

Georgeanne Botek, DPM, Medical Director of the Diabetic Foot Clinic at Cleveland Clinic, specializes in foot surgery and all podiatric conditions. She sees patients at Cleveland Clinic main campus and Willoughby Hills Family Health Center.

To make an appointment with Dr. Botek or any of our foot and ankle specialists, please call 440.312.6242.

Bone Up on Myths and Facts of Back Problems

By R. Douglas Orr, MD

When it comes to back problems, there are many misconceptions out there. Read on to learn the truth.

MYTH #1: If you go to a spine surgeon, you’ll end up having surgery.
FACT: I spend more time trying to talk people out of back surgery. Many people think that without surgery, they’ll suffer for the rest of their lives. The truth is that the vast majority of back problems can be resolved without surgery – though for certain individuals, it’s the best option.

MYTH #2: Exercise can hurt your back.
FACT: Exercise does not damage your back. In fact, exercise helps your back by strengthening muscles that support your bones.

MYTH #3: Herniated discs need to be fixed.
FACT: Roughly 80 percent of herniated discs get better on their own – no matter what you do. While waiting it out, keep exercising – gently. Take ibuprofen an hour beforehand so you can exercise better.

MYTH #4: MRIs always show the source of back pain.
FACT: MRIs only show tears and injury – not weak muscles that contribute to back pain.

MYTH #5: If I’m careful with my back, I can ever avoid having problems with it.
FACT: Degenerative change in the discs correlates to your age. For example, 20 percent of 20-year-olds have some degeneration, 50 percent of 50-year-olds, and by age 80, everyone has degenerative discs. It’s a mystery why some people have symptoms and others do not.

MYTH #6: Bulging discs are major medical problems.
FACT: In and of itself, a bulging disk means nothing. Our discs are like car tires that gradually lose air. Over time, they get flattened down and are not as cushiony. This is why our backs collapse a bit and we may become shorter as we age.

MYTH #7: The best thing for a sore back is bed rest.
FACT: The best thing for your back is exercise – even if it’s sore. We think nothing of sore calf muscles after going for a jog. It should be no different with our backs.

MYTH #8: Fusions always require additional surgery.
FACT: It seems that everyone has heard of someone who had a failed back surgery. Yet, the reality is that for the right indication, skilled surgeons very rarely perform fusions that need to be repeated.

MYTH #9: Pinched nerves make your back hurt like heck.
FACT: In general, an irritated or compressed nerve actually causes pain in your leg.

Dr. Orr is a spine surgeon who sees patients at Lutheran Hospital and the Richard E. Jacobs Health Center in Avon.

To make an appointment with Dr. Orr or one of our spine specialists, please call 440.312.6242.

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