Since You Put It That Way
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Since You Put It That Way
My Achey Breaky Joints
Did you know there are multiple types and causes of arthritis? In this episode, Mary Louder, DO speaks with Dr. Blake Miller, an orthopedic surgeon, all about the causes of arthritis, the gut-joint connection (because yes, diet can cause joint pain!) and how to prevent osteoarthritis and prolong good health from a holistic, functional medicine perspective. Listen in for the specifics and the tips!
Intro for "Since you put it that way" podcast.
Outro for "Since you put it that way" podcast
Hi, welcome to another episode of Since You Put It That Way. I'm your host, Dr. Mary Louder. And today I'm in conversation with a great orthopedic surgeon, Dr. Blake Miller. And he's up here in my neck of the woods here in Michigan, and he's a trauma surgeon, and he does a lot of reconstruction and hips and knees and things like that. And originally, Dr. Miller's from Oregon. He went to Oregon State University, and Des Moines University for medical school and his residency was at Oakland center in Detroit, Macomb Oakland Center, and then a trauma fellowship at Rutgers University. So well versed in many things orthopedics. He lives in Grand Rapids with his wife and two children and their dog. He's very passionate about joints. And so this conversation is going to be called The Achy Breaky Joint, rather than The Achy Breaky Heart. So I'm glad that you joined us on Since You Put It That Way. And I hope that you enjoy the conversation that I have with Dr. Miller. Thank you for listening. All right. Well, we're diving right into conversation here with Dr. Blake Miller, and welcome to the podcast Since You Put It That Way.
Blake Miller:Thanks for having me. I appreciate it.
Mary Louder:Yeah, it's great to see you. We had a great conversation at a recent conference, we mutually attended, and were like, we must talk about this.
Blake Miller:Yep. Yeah. I knew I found, I found it fascinating. Obviously, that was the first functional medicine conference I've been to and I was, you know, I was happy enough to speak at it. And you know, I met you and kind of dove into the, just the true science of the human body and how it works. And I found your your talk fascinating about the cardiovascular system. And there's, you know, there is a lot associated with the cardiovascular system and the and the musculoskeletal system. So it's all fascinating stuff.
Mary Louder:Yeah, yes, it is. Well, let's get right into that. So, so you know, you're, as an orthopedic surgeon, you're paid to do surgery. Right?
Blake Miller:Paid to do surgery. Yes, that is correct. Yeah.
Mary Louder:And so, you know, we always say the surgeons heal with steel, right? And so I think it's pretty amazing. And I love surgery. I loved everything about it, loved orthopedics, I was really good at it and had a lot of fun with that. So I have a special place in my heart for all the orthopods as I call them, so good folks, and one of my best friends is an orthopedic surgeon. She's a great, great person and a great physician. But tell me how and why you got into orthopedics initially.
Blake Miller:So I was injured in high school, so I love playing sports and I got injured. First was my knee when I was a sophomore in high school and I had surgery. I found the entire process to be fascinating. I had just an arthroscopic surgery, I had a screw put into my right knee. And then I went to physical therapy. I love physical therapy. I actually shadowed a physical therapist for two years in high school and then when I went into college, continued to shadow physical therapists. And then I started to shadow a an orthopedic surgeon as part of my college, a class that I could get credit for, I would sha--I shadowed an orthopedic surgeon. This was in Corvallis, Oregon where I grew up. And I loved everything about it. I thought it was the coolest thing. I broke my thumb in my junior year in high school and had surgery on that as well. And the whole process, I just, I liked the physicians, I thought they were really smart. I liked the biomechanics of how things were put together. We work with athletes. And so that was kind of my original interest in, in orthopedics was I loved anatomy, I loved the biochemical, the biomechanical aspect of putting bones back together and then functioning afterward.
Mary Louder:Right. That's cool. That's very cool. Yeah, I like that too. I really loved in fact, when I was a student, a medical student, I trained up in Traverse City, Michigan, at a small osteopathic hospital. And so we were first assists, which means you're working right with the attendant.
Blake Miller:Yeah.
Mary Louder:And I actually did a surgery and they assisted me.
Blake Miller:That's cool.
Mary Louder:So that was really a lot of fun. And so I just every time I could get in the OR, I was in the OR after I had all my other work done. So it was really a lot of fun. So, so now, so then you went in though, took it further and went into trauma surgery.
Blake Miller:I did.
Mary Louder:Yeah.
Blake Miller:So I--yeah. So early on in your career, so I entered into residency wanting to do hand surgery. I saw a really cool surgery when I was in medical school. It was a three tendon transfer for a posterior interosseous nerve palsy. And I thought that hand surgery was the coolest thing, it really affected this person's life. He, he had, he came into the hand surgeon with carpal tunnel syndrome, but he had a claw hand that he couldn't use very well. And so, so they did a surgery for him. I'm sorry, he had a drop wrist. So they did a surgery for him that allowed him to use his hand again. And so I thought that that was a coolest thing is that he goes in for one issue, and then he completely changes his life because he identifies his posterior interosseous nerve palsy. So I thought that that was all what hand surgery was, I was like, this is really going to affect a bunch of people's lives. And then I did a rotation in in residency, and it was a lot of carpal tunnels, trigger fingers, in that kind of the bread and butter hand surgery. And I did not find it to be--it's very needed, but I did not find it to be intellectually interest--interesting to me. So we get exposed early to trauma, I found that there's a lot of individuality to fractures and putting things together, and there's a lot that goes with the biomechanics of implants, what implants we're going to use for specific things, why we would use a nail over a plate, and how to address really complex issues with bone loss and skin loss and a lot of these different things. So that I found to be more intellectually interesting to me. And that's kind of where it led me down the path of orthopedic trauma is, this individuality and kind of addressing pretty significant issues in a lot of people and changing their lives in a positive way, after they've been in a pretty significant accident that they're, they are, their lives are going to be forever changed. But being a positive part of that, and allowing--trying to get them back to a functional level, or functional, functional capacity, and from a musculoskeletal perspective, I think is very interesting. Troubling and challenging and frustrating sometimes, but really rewarding in the end when you get people to the goals that they're trying to meet.
Mary Louder:Yeah, yes, I think that that's true. And it's very complex. Because as you say, no fracture is the same, in any individual. putting all that together, is just really fascinating. So then, you know, something must have been begin to stir in you caused the pause or an aha moment, because we met at a functional medicine conference. So what that means for our listeners is, that's going upstream, looking at causes, root causes, prevention, treatment using sometimes natural methods rather than pharmaceuticals. Lifes--really is lifestyle medicine is what it is. So, and all all of that is really geared to avoid you to be perfectly honest.
Blake Miller:Yeah, so you know, I look at this in a way that trauma was something that is--it is unavoidable. So you know, the the major cause of death, the number one cause of death in somebody under 40 is trauma. And so people are going to have car accidents, they're going to have all these, you know, accidents that lead to traumatic events, broken bones, and that kind of stuff. That is unpreventable. I was--through the pandemic I was, I was kind of pushed out of a--my working position where I did just a complete orthopedic trauma practice. And I got pushed into more of a general orthopedic practice at a--at a different hospital. And then when I started to see a lot of general orthopedic patients, I realized, and I realized this for a long time, but I was out of this realm of seeing general orthopedic patients--I started in private practice on the east side of the state, and I was talking to my colleague and a friend of mine, who was my who's my mentor in residency. And we always thought about having like a whole-health community where we would buy up land and then focus on food as the primary driver for health in our in our population, but we would, we would take care of this community through food, and then we would have a healthy population of people that we could work on. Well, when I got pushed to this, or just general orthopedic practice, I would see people that were just hugely sick. And you would see these problem lists that are like, you know, 30--30 things long, and you know, a medication list that you were on 20 different medications and they're like, well, my knees hurt or my shoulders hurt. And I couldn't help but think that there was a pattern of all these people with joint pain, were on a whole host of different medications. Now, the medications causing it? Probably not, but this is an indication of, that these people are super unhealthy. And we don't have--the way that we look at medicine is, is that, in the way we're trained in medicine, and I tell this to a lot of people is that we're trained in disease. We're not trained in health, we're trained in disease. And when we're trained in disease, we're told to give a medicine for every problem. There's a medicine for every single problem that's out there. And I think that there's a better way we've been practicing medicine for thousands and thousands of years without drugs, and it worked, right? And so, there were--there were, and you would see this divergence of health in a lot of people. So you would see this divergence, usually around 60 or 70, would probably be older when you were training, but, and then I noticed that this divergence of, of sickness and health started to happen earlier and earlier. And so now we're starting to see this pattern of divergence in 40 year olds, and people coming into my office all the time with horrible hypertrophic arthritis. And they're in their mid-40s. Well, I'm 42. And, and I'm thinking to myself, I don't want that to happen to me. So I want how do I prove? How do I prevent that? And how do I go down that other path that a lot of people don't take? And I think that a lot of people don't take it as because they go on autopilot for most of your life, and then just assume that somebody else is going to take care of them?
Mary Louder:I think that could be one of the problems. Yeah. So when we talk about arthritis, let's be really clear. I mean, there's a couple of different major categories: rheumatoid, and osteo. Today, we're gonna be focusing a bit more on osteoarthritis. But tell us the difference between the two. You're the specialist here.
Blake Miller:Yeah, yeah. So primary osteoarthritis, we, we consider to be more of a mechanical type of arthritic condition. So it's, we consider it to be a wear and tear disease where over a period of time your joints break down, and then they start to fall out of alignment, and then they start to become hypertrophic to you, you grow these osteophytes or bone spurs, you get this what we call subchondral sclerosis, where you actually get this thickening of the bone underneath because it's stressed. So that's what we see primarily with primary osteoarthritis. Rheumatoid arthritis is associated with an autoimmune condition. Now, the question is, is it's interesting, because I don't think that there's much--I think that their, their components are very similar in a way because you can have seronegative rheumatoid arthritis and have this pattern of arthritis, but they call it seronegative. Well, what's the difference between the--why do joints begin to become disrupted or broken down? And, and, versus a seronegative, rheumatoid arthritic patient? I mean, isn't that just one and the same thing. And so I would start to look at these people that would come into my office and I would get sent a lot of people that would have no radiographic arthritis at all, but they would send--they were sent to me for joint pain and arthritis. And so then I started saying, there's something wrong here because I see this pattern where people have no radiographic arthritis at all, but they have horrible joint pain. Or on the other hand, you have horrible radiographs with no pain. So what's the difference in what separates the two? And so then I had to start looking at it a lot differently, So then I started to look at food as being an inflammatory because it didn't make sense. And so then I started saying, well, the people that don't have any radiographic arthritis, let's stay away from gluten and dairy, because we know that problem. The food system in our, in our country has--is very poor. And a lot of people will just eat processed food, and they they've made us believe that a calorie is a calorie, and those are inflammatory in some way. And so I just started that's certainly not the case. When you look at the nutrition science and you actually dive into the nutrition science, you realize that food is medicine. And it can, it, you can, you can treating them with diet and saying, remove this from your dial in whatever physiology you want with different--with whatever, different vitamins, different minerals, anything, and then you can modulate the immune system. And once you start to modulate the immune system through diet, now you diet and see what happens. And I've had a handful of patients don't have joint pain anymore. Now, I don't think that this is right for everyone. I mean, so people that come in with horribly destructive arthritis, diets aren't going to change anything, they've got a they've got disease that needs to be that do that, and they'll come back six weeks later that are addressed. But when we start looking at the literature behind arthritis, and we start to replace joints, 20%, up to 20% of people don't like their total knee replacements. And I think that the reason is, religious to actually doing that, and removing that from is because--a couple reasons. One is we can't re--we can't reconstruct the joint the way that it was naturally made. And the other thing is, is I think we're treating the wrong their diet. And they'll come back six weeks later, and problem. And so, if we're treating the wrong problem, then, of course, you're not going to get any relief from a total joint replacement. If, if the arthritis isn't what's driving the joint pain. If it's immune, if it's immune-mediated, they're like, I have no joint pain whatsoever. then you're still gonna have joint pain after it's replaced.
Mary Louder:Okay. And so immune-mediated could mean that it's not, like you said the seronegative, or meaning your labs are normal, or low nor--barely elevated in rheumatoid factor and anti nuclear antibody and things like that. And those are the folks that come and see me all the time. My labs are sorta normal, I have this joint pain or I have these conditions, and no one seems to know what's going on. And that, you know, creates this conundrum. And the other, you know, the other is sometimes it's just straightforward. I think of like Lindsey Vonn. I love her as a skier and amaz--I could never go that fast going down a hill, you know?
Blake Miller:Oh, I get it!
Mary Louder:And oh my gosh. But you know, her, she has had literal crashes, and she's set for a knee replacement coming this spring. And that, you know, I mean, is that just mechanical, because she just had so many fractures and things like that, most likely so.
Blake Miller:Yes.
Mary Louder:And she looks by her diet, nearly gluten free, I have to say, and gluten-dairy. She's, she's an amazing, still amazing elite athlete.
Blake Miller:Yes.
Mary Louder:Yeah.
Blake Miller:Yeah. And that's the thing. It's like, you look at some of these athletes, and they, they're, they're workhorses. And these, these athletes, they have a team of people that are keeping them healthy. And so you have to think that her joint issues are--your body's not designed to do that. You know, these, you look at these elite athletes, and they're elite for a reason. But, I mean, we would see, we saw a couple of professional or, you know, retired professional football players when I was in residency, and we would see, you know, some of these professional athletes, and let's take Kobe Bryant for, for an example. He's, you know, 40, he had multiple injections over in Europe to, to for this arthritis that was developing in his knees, your, your joints are not designed to play 82 games, you know, 40 minutes a night, sometimes longer and, you know, for 20 years. It's just not, they're just not made for that. And I think that if you have those people that can do that are genetically lucky. But again, your body is going--that's that is just a lot of a lot of stress on your joints. And these--I mean, he's a huge man, he's 6', 6'-8", and probably 230 pounds, that you're just gonna break down at some point.
Mary Louder:Right. Yeah, just and that's the mechanical part you're talking about with osteoarthritis. So okay, so then, you know, foods, yes, for sure. gluten, dairy, some folks really have a sensitivity to that. And different than a food allergy. You know, it's not the scratch test on the back. Yeah. And it's a test that we do through blood that looks at IgG, which is just a component of where the immune system remembers something's triggered it. It's like this, it's like this big Memory Box, the immune system says, yes, I've been triggered. And I now have a have a recording of that. So sometimes that can even be kind of nonspecific, meaning, Well, when was that? How long ago was that? How strong is that? And I would say, that becomes difficult for us to know, because we're looking backwards, and we don't have--and we have abnormal labs now, but we don't know when those became abnormal.
Blake Miller:Right. Yes.
Mary Louder:I think that's very challenging. So I understand what you're saying about our food system and our lack of nutrition in the food and the hyper processed foods, I call them Frankenfoods, right? And then, and looking at removing some things that you could have a sensitivity to, but then underlying that, it's going to be a couple of things: the microbiome and the gut. So if you were to describe the--let's, let's pick a joint, the gut to hip or gut to knee connection.
Blake Miller:Yeah. Yeah.
Mary Louder:Literally, no pun intended, walk me through that.
Blake Miller:Yeah. So, we'll, we'll take the knee, because the knee you get arthritis in three times more commonly than the hip, I think that hip arthritis is a little bit, a little bit more nebulous in terms of development of arthritis. Now, the knee arthritis is, you look at the the gut, so we look specifically at the Klebsiella species and Proteus species, and those, if you have high levels of colony-forming units of either the Klebsiella or Proteus, this is when you're going to start to see an immune reaction to the joint. And so you're gonna see ankylosing spondylitis, rheumatoid arthritis associated with those things. Now, you don't have to have, like if you have those in your gut, then you you have to look at that specifically. Now again, stress, high levels of streptococcus can lead to arthritis as well. And so, you know, the environment that--your, your body is, is a very important environment. So, I always talk to people about this is, it's like the rain forest. If you remove a species of plant, it's going to affect other plants around it because that--you don't know how complex the system is until you start to remove things and start to mess with things. And then when you start to mess with things, you see how important each one is, and you don't really want to mess with stuff unless you really know what you're doing. And the interesting thing is, is that, if you Look at the arthritis in a patient, there is some, some research believe that you--not only does the affected joint, but the joint mechanics may also affect the gut as well. And so the there's a bidirectional or possibly a bidirectional approach to this. And this is when, when we're getting into talking about gut issues with a lot of patients, I often tell them, we don't know if it's the cause or the result of these issues, or a combination of them. And so, you know, I think that the, the microbiome is a fascinating field of research. And I think it's really early in its infancy, and we have no clue what we're going to find from it. But I think we're going to find a lot of really good treatment options for a lot of people with the gut. I work with an anesthesiologist that is really kind of into this as well. And he, he had an FMT so a fecal microbiota transplant when he was in residency, and he said, it changed his life completely. The day after he got it, he was like a new person. And it was really, really good for him in terms of his health and returned a lot of his health back. And so the microbiome plays a significant role in your overall health. And it's it's literally everything, including joint health. And I think it's going to be fascinating to see where it goes probably over the next 10 to 15 years.
Mary Louder:Yes, I--yes, I agree with you fully. And I think--so, the microbiome is in this through us, but not of us. And just like our GI tract is in us and through us, but it's outside of us, even though, even though it goes through us. So which you know, it's like, what? Yep, that's exactly what I said: outside of us through us.
Blake Miller:It's a challenging concept to wrap your head around. But to think that the GI tract is truly outside of the body, it's, it's kind of a--it's something that I had to--I understand it now, but when medical studying, how is it, how is it outside of our body? And then you realize it's just a tube that goes through us.
Mary Louder:Right.
Blake Miller:So like our lungs, our lungs are outside the body too, so.
Mary Louder:Yeah, and so I guess we could say, eat dirt and not die, that would be the goal, right? Because we want to have a good robust microbiome, we want to have, you know, a diverse, but we, we also want health. And so what we're finding, and I remember being at a conference a number of years back, and it was on the microbiome. It was on--and it was all scientists, I was one of the few clinicians there. And they go, how do you find the perfect stool? I said, Well, you don't. You just start with what's in front of you. That's called the patient. How can you even make a decision? Because there's no perfect stool. I said, That's right, because you just have to start with what you have. And you have to almost like reverse-engineer, you know, find those pieces. So we're finding--
Blake Miller:It's probably different for every different person too, right? That's what's the hard part about being a clinician is you, you don't know. There's there's no perfect reference to for the microbiome. You just got to figure out, how do we address this patient that's sitting in front of me?
Mary Louder:Right. So give me five tips, maybe three. Three to five tips. That would that could be great golden takeaways for our listeners on this.
Blake Miller:For joint pain?
Mary Louder:Yeah.
Blake Miller:So I think obviously, the--if you do have joint pain, I would always limit--I kind of push people to the autoimmune paleo protocol, which would be no gluten, no dairy, no lectins, which would be tomatoes, potatoes, eggplant pimientos, those kinds of things. And then no egg whites. So egg whites tend to be inflammatory. So I start there with regard to if you don't have any arthritis, radiographic arthritis, but you have joint pain, we start there. Number two is keep your joints strong. So you have to maintain strong joints, so lifting weights is really really important to maintain strong joints. Because if you--there are static stabilizers in the joint which are your ligaments that connect bone to bone, and then you have your dynamic stabilizers which are muscles, so your muscle the bone connection, the tendons, are really important for dynamic stability in the joint and so if you don't have good dynamic stabilization of the joint, you are going to leave your your joints susceptible to getting arthritis. And number three is really kind of looking at hip and knee arthritis specifically. And it's kind of weird because ankle is spared for the most part from primary osteoarthritis. Elbows are, wrists are, so you get this just weird pattern. I think part, part of the problem and why people get so much arthritis is because they have this subclinical neuropathic problem, whether, whether this be a mitochondrial issue, so their their nerves aren't working well, because they can't produce enough energy to reproduce their resting membrane potential, or there's a compression in their spine and they lose some strength. It's subclinical. So if let's say that you have, you're going on a walk, but you can't run, this would tell us that, well, you have to recruit more muscle to run. And so people just say, Well, I'm not going to run. But this would give us an indication, okay, the neuromuscular input that you have, is insufficient. So it's almost like a brownout where you just don't have enough electricity to control that, that, that, that joint strength. And so if you do your activities of daily living, you're going to live under the threshold where you don't recognize that you have this joint instability. But over time, you, this becomes, if you get more compression, or you're, you're got blood vessel issues, where you're not delivering oxygen to your nerves for them to function, or your muscles to function well, then, you will start to lose your dynamic stabilization. And then you'll, you'll get pain that way. So I would--I'm, I'm always stress your body. So exercise is always really good, and then always, if you can't do something like walk a flight of stairs without getting tired, or if you can't run because you, you have a limp. This would give us an indication, okay, we need to strengthen something there because we need to protect our joints from, from damage.
Mary Louder:Okay. That sounds great. So diet, strengthening, stabilization, and finding someone to get a good opinion and really get a good program together.
Blake Miller:Yeah.
Mary Louder:Sounds great. Well, this is a whole different look than just waiting for the other shoe to drop, meaning the shoe you can't put on 'cause you can't bend your knee, right. So, so we won't wait for that forboding joy. We'll just--oh my gosh. So lots of action here, lots of action steps. So I appreciate this. I think this is really important for our listeners to hear. And we're going to be posting your information too, along with this podcast. So if people want to reach out because I know you're doing some telemedicine with folks.
Blake Miller:Yes, my telemedicine practices freedom functional medicine. I also practice general orthopedics in a, in the commercial, conventional setting, too. And so I'm happy to see you at the office there. But yeah, my my primary goal is to kind of take care of people, and the conventional model, medicine model is limited for a lot of this stuff, because insurance companies just won't pay for it. And so I think conventional medicine is really good for a lot of things. So end stage arthritis, do total knees and total hips do well? In the, you know, they do for most people. It--for the right patient, I think they are an excellent, an excellent treatment for. But most, most clinicians, if they, you know, specifically orthopedic surgeons, because that's what I'm most familiar with. If you know, if we have a hammer, everything's a nail, and so knee pain to them is like, Oh, just a total joint. And so that's why we get into this process of, well, we're not thinking about the immune system and the role of food that has--we have on joint pain and that kind of stuff, because we're limited in our education. And I think that--I don't know that there's not a lack of interest. It's just there's so much stuff through commitment, conventional medicine, there's so much stuff with regard to the paperwork that we have to do and they were always kept busy. And we're trying to to catch up to the, this New Year's like, what do we have to do for charting to you know, so we can get paid what we need to get paid? And, and doing this kind of stuff that they've--they lose interest in, they don't really study anything outside of work, because they're just so overworked during work. And we work many hours after work, just trying to catch up on charting and everything else like that, that we just don't have enough time to stay up on this stuff.
Mary Louder:Yes. So, well, I appreciate that you've stepped out of the box to really help people and to give them a very good understanding and very good options for surgery with good recovery. And even like a prehabilitation should they need to have a surgery, and then even really prevention, both primary and secondary. So it's great. And this is a great conversation, I thanks--thank you very much for coming on our podcast and sharing your wisdom with us.
Blake Miller:I appreciate you having me. Yeah, I really appreciate it.
Mary Louder:Yeah. Well, well, I look forward to working with you as we go forward. So thanks very much.
Blake Miller:Yes, thank you. I appreciate it.
