Inflammation 101

The symptoms of your ailment or injury are due to inflammation. Inflammation is a natural function of your immune system resulting in redness, swelling, heat, and pain in response to damaged or infected cells and tissue. After an injury, inflammation is normal and is the first stage of healing. When a body part is injured, blood flow to the area increases, and certain immune/inflammatory cells start the healing process. Signals are also sent to the brain saying that the body part is injured and needs to be protected. Acute inflammation is the proper reaction to an injury and is crucial for proper healing, but chronic (long term) inflammation is not useful in healing and is considered a disease process. In an acute inflammatory response, the immune system eventually shuts off the inflammatory process once the damaged tissue is healed. Unfortunately, this is not always the case. As the name implies, chronic inflammation is essentially acute inflammation that persists for prolonged periods. There are many causes for chronic inflammation, but at the root of many orthopedic ailments is a defect in the process to shut off inflammation. Chronic inflammation can thus result in pain without an injury, pain from routine body movements, or pain long after the injury would have typically healed. 

Chronic inflammation of the joint cartilage is called arthritis, of the joint lining is called synovitis, of the tendon: tendinitis, of the bursa: bursitis, and of the nerves: neuritis. Once a patient is diagnosed with chronic inflammation they are often treated with anti-inflammatory medicines, physical therapy to restore motion and muscle balance (a weak or stiff joint is a painful joint), anti-inflammatory injections, or surgery to release, repair, replace, or excise the damaged tissue. 

With imaging we can see the signs of tissue damage on an x-ray or CT scan or we can see the damage on an MRI or ultrasound. After decades of performing these studies, we have learned that despite signs of tissue damage many patients do not have pain because they have less chronic inflammation. We see patients with bone on bone arthritis with little discomfort, patients with rotator cuff tears with no pain or loss of function, patients with degenerative meniscal (knee cushion) or degenerative labral tears(shoulder or hip cushion) without pain, and patients with degenerative disc disease or stenosis of the cervical or lumbar spine with no pain. Certainly, some patients may have a higher pain threshold, but it is far more common that they have less chronic inflammation and therefore less pain.

Chronic Inflammation is on the rise in recent generations and is the most common reason people come to see me for treatment as an orthopedic surgeon. It is also the top reason patients ultimately need surgery. The bad news is our population's general health is worse in many ways than previous generations, but the good news is we now have a better understanding of health and treatment of illnesses beyond medicines and surgeries. Many of us are aware that certain lifestyle choices increase the risk of diabetes, heart disease, high blood pressure, cancer, and obesity. Most of us are not aware that it also results in chronic inflammation and will make it more likely you will struggle with pain in your musculoskeletal system. If you wonder why you are frequently injured, slow to recover, and struggling with the aging process it is likely due to chronic inflammation resulting from overall poor health.  

Peter Attia M.D., a lifespan expert and author of Outlive, puts your overall health into 5 baskets: nutrition, exercise, sleep, stress management, and medicines/supplements. If you are struggling with chronic inflammation and want to avoid seeing the doctor on a regular basis you may want to look at each of these baskets and consider some lifestyle changes. 

In orthopedics, we see two groups of patients. The first group is generally healthy. They see us with an injury, receive treatment, recover quickly, and then we do not see them again until the next injury or accident; often many years between visits. It is common to only see or hear of them when a family member or friend is referred. The second group is not healthy and suffers from chronic inflammation. We see them year after year or even month after month. When one problem is fixed we move on to the next problem. These are our most well known patients and we enjoy treating them and our practices depend on them for success. The second group has gotten way bigger in recent decades. We used to think this group was just unlucky with bad genes. We now understand we have no control over our genes we inherit, but our lifestyle controls what is known as epigenetics or how our genes are expressed. In other words, genes run in your family but you can control to some extent how your genes work. If you are interested in jumping from the second group into the first group a change must occur. Change tends to occur in 4 seasons. One driver for change is when someone hurts enough that they have to change. If you are sick and tired of being sick and tired this could be your season to change. Change also occurs when someone is inspired. This could be when a family member or friend makes a lifestyle change or maybe you notice people your age doing things you have not done in years. This could be when you realize Tom Brady was playing football and taking hits well past middle age, but you struggle doing simple physical tasks without aches and pains. This could be when you see an actor like Tom Cruise doing his own stunts. Social media is filled with inspiration if you are looking at the right material. Change also occurs when people receive enough. This could be because they receive enough time to work on their health, receive enough money to invest in their health, or even receive enough attention from someone to help them work on their health. The trick is if you commit time to your health you will gain time and improved productivity in exchange. If you spend some money on your health you will save far more money in health related expenses down the road. If you work on your health you will eventually receive attention from a whole community of people interested in health. The final season of change is when you learn enough. This is the whole reason for this writing. Most orthopedic patients do not correlate their illness or injury with their overall health and lifestyle. With knowledge you have a choice, and you no longer have to be a victim to poor health. Your doctor will remain focused on your chief complaint every office visit because that is how they have been trained, and how they can make you happy as a patient. They may suggest or hint at lifestyle improvements, but it will always be a difficult balance between truth and cruelty. If your body is falling apart and being destroyed by chronic Inflammation and you throw your back out or have an arthritis flare your doctor is unlikely to use your appointment time to discuss improving your overall health. At no point does a doctor want to appear a bully,  but the fact of the matter is lifestyle is often a major contributor to these issues.

Finally, the United States has the best Healthcare technology and best trained physicians in the world.This is where the world travels for advanced physician training and advanced treatment. In discussions about healthcare reform, it is quoted that we rank low compared to other advanced countries and that we spend way too much money. The reason we rank low is because we do not often consider lifestyle in our health system. We eat way too much of an overly processed sugary diet. We are inactive or we have manual labor jobs for which we do not properly prepare. We do not get proper sleep and walk around in a constant state of fatigue because we do not prioritize sleep. We are overstressed and often ignore our own mental health issues. Many of us just depend on this system to put us back together or keep us functioning year after year. The cost adds up for the individual and the country. If we want to improve health care spending for our nation, we want to decrease the frequency people need the healthcare system. For the individual, the cost of healthcare can be crushing to personal finances. You can not wait for health care experts or politicians to fix the system and make your healthcare more affordable. Your best option is to live a healthy lifestyle, maximize your epigenetics, and decrease your own healthcare spending. My hope is you look into all the baskets that make up your own health.

Why is an orthopedic surgeon concerned with the overall health of the patient as opposed to just a technician who treats each problem as it comes along? It is well established that chronic inflammation leads to heart disease, strokes, diabetes, and obesity just to name a few. These diseases are often silent killers, meaning the patient is unaware until the disease is severe or it is caught in an annual checkup. In the musculoskeletal system, however, chronic inflammation presents itself immediately using pain as the shot across the bow. We need to recognize these warning shots and work on making ourselves healthier and resistant to disease and injury.