You know, people who present with trigger finger are looking at their A1C's and almost 100% of the time that A1C is deranged. So you don't go to the doctor to look at their, you know, no one says, "Oh, my A1C feels off," right? But they say, "My finger's not working." Often I'm the person that people see when they don't want to have surgery, so they're saying, "What can I do to avoid that?" And sometimes it's inevitable, but sometimes it's like, "Okay, well, if you really don't want a new replacement in the next year, then here's the things you have to do." It's like, "Well, first of all, it's better be moving than not moving. And I'm always telling people that, you know, every pound on your body is four times as much pressure on your knees. So you might want to think about that, even a small weight loss can have like a four times magnitude reduction in stress on your knee joints." I spent a lot of time talking about butts, actually, so especially for women. Today with us, we have Dr. Amy West, who is joining us from New York, from New York. I've met Amy a couple times now at conferences, and she actually came into the house. We had to stay together back a few months ago. Amy, I guess for those who don't know, you could tell us your background. I am a sports medicine physician, non-operative sports medicine physician in physical medicine and rehabilitation. My work in New York, I went to Harvard Medical School, then my residency, Harvard, QM, and R. I'm a lifelong athlete, a cross-fitter, I'm a companion, a cross-fed athlete, Olympic weight lifter, so I'm super involved in fitness. I've been talking about that stuff for a long time. So, yeah, that's sort of being short. Yeah, me too, I'm talking about that stuff for quite a while now. Many people are unfamiliar with the specialty physical medicine rehab. Maybe just give an overview of what that entails. Yeah, so we're the best kept secret in medicine, as far as I'm concerned, but physical medicine, rehabilitation. So we focus on the physical manifestations of physical medicine. So we focus on the physical manifestations of disease processes. So how does these affects your body and affects your function? And that's pretty broad. You kind of sub-specialize all the things. I primarily focus on sports injuries, but we also deal with things like traumatic brain injuries and how that affects your functions, final court injuries, strokes. So we're not treating the actual issue like a stroke. That's a neurologist do that, but then we deal with how the stroke affects your body and your walking, your specificity, and how you go the bathroom and all that kind of stuff. So, certainly with cancer, we work with cancer rehabilitation. Oncologists take care of the cancer treatment, we take care of how that treatment and how the disease affects how you live your life. And that's the theme in physical medicine rehabilitation. So that always appealed to me in dealing with people's quality of life and their function, rather than just attacking the issue with medications and things like that. Now, there's both outpatient and inpatient. I know when I was doing my repeatable residency, we did one month of PM and orbit. It was an inpatient sort of setting, and it was interesting. It was nice because there were no real emergencies in that situation. I was pretty non-emergent stuff. So you know, a little more stable. Although we get cold to put in IVs and stuff like that, but not occasionally. But anyway, so you're primarily outpatient, I'm assuming? Yeah, so I'm all outpatient. So I'm a human art physician by training, but I work for an orthopedics department. So I'm essentially kind of part of that department. And because I'm not an orthopedic surgeon, I don't have to say a call for them. So I'm in this no-man's land of call, which is this nice. So I don't do any inpatient work anymore, but that's all outpatient for me. Obviously, you and I understand that metabolic health impacts more than just diabetes. I see it manifest in orthopedics and probably damn near every special at this point. Let me get your thoughts on health in general. Obviously, healthcare has, I think, some holes in or some blind spots when it comes to metabolic or chronic disease in general. But what has been your, I know you do a fairly low carb diet. I think you eat a lot of meat like me and stuff like any or an athlete. So I mean, how does it impact the people you deal with, you think? Majority of the patients I see have multiple chronic metabolic conditions, almost everybody. And I work in sports medicine. I do see athletes, but that's a small percentage of actual people that I see who have just aches and pains and injuries from other things. The majority of patients I see are actually people who are multiple chronic diseases in another hospital with those things. And for the most part, aren't particularly active. Or have very misguided understanding of what exercise is or what nutrition is. They've been the medical system for so long when they're being told things that up to this point have it really helped them as far as how to eat and what kind of exercise they should be doing and how often. So often they're confused by all that. And then I see as far as metabolic and how metabolic issues and orthopedic issues often are going hand in hand. When people present here with something like a trigger finger, for example, or adhesive capsulitis or frozen shoulder, that's what brings them into the doctor. And then looking further into their metabolic health and it uncovers a whole series of things that have been deranged for a long period of time. There's actually a research study going on here now where people who present with trigger finger are looking at their A1Cs and almost 100% of the time their A1C is deranged. And they wouldn't have known that because they don't go to the doctor to look at their... No one says, "Oh, my A1C feels off." But they say, "My finger's not working." So let's let me get that checked out. Often these things are part measures of much bigger problems. And we're catching them in orthopedic space first. That's something that's definitely been popping up quite a bit. And then on the other end of that... No, go ahead. I was going to finish off. Another thing I see quite often. So I work... I've been doing CrossFit for a long time. I had a lot of friends in the CrossFit community. I work at the CrossFit Games as part of their medical team there. And as a result, I see a lot of local people who are CrossFitters, own gyms, et cetera. And they'll come in with issues, long-standing aches and pains. And I'll see that, for example, I have one lady who owns the gym to know CrossFit. She's in her 50s. So I had some trauma to her shoulder a long time ago. Never really thought much of it. And she's like, "Yeah, it hurts a little bit when I do some pull-ups." And I saw her x-ray. And her joint was demolished. There was no cartilage left in there. Osteophytes, like bone spurs. And it was mangled. And other people with that underlying pathology, they can barely move. Whereas she was like, "Yeah, my pull-ups aren't what they used to be." And I see that time and time again, especially older people who have been active, who are swimmers, runners, et cetera. The amount of pain that they're having is so much less compared to someone with minor changes on their x-ray who can barely move. And what's the differentiator? It's essentially their metabolic health and their physical activity. Yeah, I can remember when I was doing my residency, our foot and ankle director. He said he could literally diagnose diabetes by examining the stiffness in their Achilles because then we had this change in some of the tissue qualities. You probably are quite aware. Yeah. One of the things that, you know, one of the things that even as an orthopedic surgeon, I never learned this. Or at least wasn't emphasized in any of my training. It's not really particularly emphasized in any book unless you really look for it. It was perioperative nutrition. You look for, you don't want somebody to have a really low album in and they're sick and kick-exic. But outside of that, a little interesting to support higher protein intakes in and around trauma, surgeries, recovery, healing. Is that something that you get involved with and is like, "Okay, you need to improve your protein quality content while people are healing?" Yeah, so I do see that a fair amount. Now, either so, I often am the person that people see when they don't want to have surgery, so they're saying, "What can I do to avoid that?" And sometimes it's inevitable, but sometimes it's okay. If you really don't want a new replacement in the next year, then here's the thing that you have to do. And it's fixing your nutrition. It's losing weight. And there's injections and stuff that I can do to help with that. A lot of this is, you don't have to optimize everything else with a lot of people who need to lose weight, and then they go, "How do I go about doing that?" And then, yeah, just talk about protein intake, things like that. And even if you end up having the surgery, you'll work tougher faster. You'll do better on the back end of it. So a lot of that talk is either leading up to surgery or trying to prevent it, or at least making that process easier on the back end. I can remember when I started putting patients on low carb diets, and I had them in the hospital and post-op day one knee search. And this is the back end of the day we keep them for a day or two. Now, now a lot of it's outpatient, but I was just remarkably impressed at how little pain they had on post-op day one relative to other people. It just seems like the inflammation was tamped down, which obviously that's a good thing because when it comes to mobility and better quality experience. So, let's talk about the role of strength training in health of the joints, preventing injury, and even in a compromised joint. Because a lot of people are like, "Oh, my knee, I have to lay off it all the time. I can never use it again." What are your thoughts around those things? Oh, yeah. So that's a conversation I have quite frequently. People say, "You all have this name to think, so therefore I should just do nothing." Or, "Should I exercise or should I strength train?" And I was like, "First of all, it's better be moving than not moving. I'm always telling people that." Yes, if you do nothing, yes, maybe you won't make that meniscus care bigger, but you're going to cause yourself a whole bunch of other problems. Might not be okay. All the other benefits of exercise that you're losing. Not to mention building up the strength around the joint, proving the functional movement of the joint, the movement patterns of your body. These will only help the situation, help with your pain, help with the function, help with the strength around the joint. So something that I have to combat that I do quite often is, "If I've hurt myself therefore, I shouldn't do anything, so I might make it worse." You will definitely make a worse by doing nothing. So you'll make your health worse by doing nothing. So you have to get moving. Yeah, I cannot tell you how many sedentary I did knee replacement patients. I did knee replacement saw. And a lot of that is we're coming to find out that even though there is this wear and tear mechanical loading component to joint, where there's a big biological component in having all this extra BC with inflammatory cytokines, high insulin levels seems to contribute to that. And the other thing that a lot of people will talk about joint stability, like for the shoulders of your right example, because it's our least stable joint generally. It's got such a large degree of range of motion or freedom of motion. And that's a joint structure or salutumence, but also the muscle places that role in dynamic stability. And so when you have, I talk to you, it's like driving your car with tires that are out of balance. Eventually they're going to wear a lot quicker so that the muscles just hold things in a position you're supposed to be in. What do you, so do you ever give nutrition advice to your patients? Is that something you're comfortable doing allowed to do in a position you should be able to? Right, so it's a little bit of a tricky situation. So yes, I do. I tend to just focus on like protein goals because I feel like that's not a very kind of clear pet thing. I can really say, try to hit this. If you're hitting that, then we can distill down into further advice. So in general, in my regular clinic practices, I can see 40 people in a day. It's fairly fairly quick visits and most of the people that I see in general are probably not interested in a lot of that. It's like, hey, this pain fix me. I gotta get going kind of thing. So in those situations, that's how I deal with that. But when people express interest or ask me, I'm more than happy to talk about it and give them advice. And I will talk to them more in depth about it. It's funny, especially in working in big health systems like this, if someone can be 300 pounds. And if you say something about, hey, you need to lose weight. Regardless of whether you're right, how you say it, how it's introduced, the patient here is the doctor called me fat and they'll write a review of you online and you'll get in trouble for it. You have to be careful with how those conversations come up. People express an interest to me or say, I know I need to lose weight. And then XYZ, the tactic from that perspective saying, hey, every pound on your body is four times as much pressure on your knees. So you might want to think about that. Even a small weight loss can happen before times magnitude reduction in stress on your knee joints. So that's really important. And people said that will stick with people. They'll take that and then we could get it more to the nutrition stuff. So I do some like online education through a company called Best in Class MD. So people really want me to break down and go into the weeds with their nutrition and exercise plans. And I have like more time to do that there. But like my everyday practice, it's more like people ask, they'll tell them and I'll give them some guidelines. How many people actually are interested and will stick to it? It's probably difficult when you, when probably a majority of patients would benefit from better nutrition. It was like biting your tongue. I remember when I started doing this and I was, I first thought, I was just going to hand out fliers to a certain selected number of people. And then all of a sudden I was handing out 30 and 40 a day and my client was like, all these people made this stuff. It was just crazy. I used to do this kind of crazy. When I had people come with carpal tunnel syndrome, I just thought that I think carpal tunnel is probably a metabolic downstream effect and I was testing insulin levels. And I got some really weird calls from the lab. Why are you testing insulin? Yeah. Yeah. And they were high. It was surprising. They were high. What about, well, let me just, you mentioned protein goals. What are the protein goals for in your population? It doesn't matter like injury versus how do you determine that? I usually will just say a gram per pound of body weight, ideal body weight. So in general, I'm telling people like most women say like around like 140 grams a day roughly and just trying to hit that for trying to get, or trying to get a decent amount of protein per meal with making that the priority of the meal. So try five, five ounces, five, six ounces of some kind of protein per meal and just see if you can get that. If people are mastering that, then we can break down getting to the weeds with specifics and goals and stuff like that. Most people, especially women, but not coming anywhere close. I was talking at a woman's health symposium about that long ago and it was like a breakfast thing and a big breakfast buffet out and I just looked at it and I said, look at everything on that table. There is no good Jessica routine on that whole entire table. It's all muffins and damages and just crap that was on that table. And I said, there is nothing there, nutritional value, health symposium. So let's start there. Let's break that in that down. And everyone was like genuinely surprised. They really were like, oh, wow, they had no idea. So I think just like breaking that down first is like the first step. You know, if it's a brand muffin, though. Yeah, right. That's like, yeah, right. All these new muffins. Yeah. Yeah, that's a medical conference. They always have garbage. Let me go. Let me talk a little bit about your athletic stuff. So you said you want to. I think you said you want to Harvard and what kind of athletics have you done throughout your life. I played everything as a kid. I was into all kinds of things, but I ended up playing semi professional softball in Europe for a period of time after college. So that was doing that. And then ultimately when I got into med school, you hit this point like in your adult life, you're playing T sports your whole life and then it stops and you're like, what should I do? I guess I'll start running, which I was like a huge fan of. And then I stumbled upon across the gym while I was in med school. And then that was it for me. So I've been doing that and competitively over the past 12 years. And then as a result of that, started Olympic weightlifting. So I could be in that as well, giving me a nice sort of second chance at being somewhat of a conveyive athlete. Yes. Particularly as you get older, I'm gosh, I'm almost 60 now. There's not a lot of team sports where anybody's taking anything any seriously. And you worry about the people going to break. I can remember when I was doing jujitsu. I would mostly go against younger guys because every time I went against an older guy, my eyes, I thought I was going to hurt him. That's like a race of frail. Yeah. And also I played some recreational sports leagues in the area and all of their women's legs and all the women for the most part that were my age were either too injured or overweight and just couldn't couldn't physically do it. So then I was like, I'm playing with 120 year old. I should put something else in here. But yeah, so it's not uncommon, unfortunately. Yeah, for sure. So what about so the orthopedic group that you work with? I'm sure they do a lot of job replacements and trauma and all the stuff that I'm sure you end up with. Are they on board? Are they because I was fairly progressive when I came to post opera? Yeah. I had my total joints. I told them fine, go look, wait, I thought that was healthy for them. Is there, is that generally the thought now? Obviously they've employed you. I'm sure it's with the message. Yeah, I mean, it's all over. So I worked for the biggest health system in New York. So we have a ton of orthopedics or a dime, and all of them. There's so many. I am one of three non-operative people in the department and only one of two PM&R doctors in it. When I was hired, they actually didn't know that PM&R doctors did sports medicine. They were like, oh, wow, that's interesting. So I got brought. I was like a new thing to the system when I came in here. But yeah, they range as far as what they're prescribed and what they tell them to do. There's some surgeons that are more lenient than others. There's some more focus on certain things than others. I see people from all over. What is far as like things that you find that are obviously there's a strengthening and range of motion stuff and nutrition, but I know there's a lot of different modalities out there. Some have come and gone. Some have been somewhat useful. Some have been kind of a waste of time. What do you find is actually useful in your practice? Yeah, as far as the things that I'm doing here, we've started doing some ortho by a lot. As far as for different pathologies, kind of not the things and mild to moderate cases, where things like PRP are put in a rich plasma, which has some promising results if in the right patient population, the right injury, the right setting. I think a lot of people pushing it for everything when it's not going to work. And then that causes some kind of bad things or just waste people's money, but so different kind of ortho biologics, extracorporeal shockwave treatment, something that has had some promising results as well. So I'm dabbling in those things. That was primarily using this lithotrup suit. I know that was one of the initial place where breaking up kidney spasms, but my thought around whether it's PRP or stem cells or some of these now peptides that people are using is that if I liken it to recarpening my house and if my house is on fire, it's not a very good time putting a carpet in. So put out the force. I think if you can fix the metabolic damage, it's going to have a least better chance of being at the case. So I know I think last I looked at the academies orthopedic academies position paper on things like stem cells and PRP. They were like, kind of mad. There's not a lot of strong evidence. We can't strongly recommend who knows. And obviously there's champions that their whole clinic is based on that. And so they see. It's also not very standardized right now as far as when you say PRP like different places using different concentrations and different protocols. And so that's something that used to be hammered out a little bit more clearly. Yeah. And when you say it didn't work, we didn't do the right formulation. I hear that all the time. I don't know. Maybe you should maybe just stop eating cupcakes and. Same thing with peptides. I mean, there's some really interesting things that they help. But it's that's we got to fix all the underlying stuff first because that's like a drop in the bucket. So as far as so the CrossFit stuff. So let me ask you this because obviously CrossFit is there's a lot of detractors across. I think it's pretty cool. I think I thought about doing it for a while, but then I would just, it was during COVID and it got shut down. I was like, I don't want to stay. I don't want to stay around in a mask and do it from home. And it's just I ended up doing. I want to do it soon. But as you see me, I'm tall. I'm not the ideal CrossFit asset. I'm too heavy. I'm strong enough, man. Strong enough. Yeah. There's some things I could do like a deadlift, like a party of good wall balls and stuff, but some of the hands, the gymnastics stuff I'd struggle with. But let me ask you as a CrossFit asset, who I presume, correctly, if I'm wrong, you're on a fairly low carb diet. How does that work for you? Yeah, I'm not. I do eat carbs throughout my training. And I thus far have not had any issues as far as the issues as far as running into issues that problems with my training as a result of restricting that in any way. Like I said, I maybe around, depending on the day, about 80 grams of carbs a day, maybe. And like I said, I haven't had many issues with that. It works for me. Everybody's different. Everyone has their own needs and things that works for them. And there are some people, and certainly in the CrossFit community, we should be eating way more than that. And for some people that need that, it works better for them. For me, it's like, I've gotten used to it at this point. Yeah. I presented in front of one of the large strength coaches meeting back a few months ago in South Carolina, some called Summer Strong. It's got a lot of top collegiate strength coaches and some of the NFL guys. And basically, the conclusion, I think, is whatever you're chronically adapted to. And if you're chronically adapted to a low carb diet, you can do pretty damn well with that. And it may take a while. It may take many months and even years and taking some cases to really be. And that's what the literature seems to support. The scan amount that's out there, there's a very little literature that looks long term adaptations around this stuff. How do you, because you, I think you said the way you're doing Olympic lifting as well, obviously crosses the introduction to Olympic lifting for a lot of people. It's part of their programming. I assume you gravitated toward that because you're fairly good at it. Part of Olympic, I've always been strong. I was like, your girl is just strong, but I didn't really know much how to channel that. And then with the Olympic weightlifting, because it's so checkable, the crossfit, you do it. And if you want to go, I just plateaued with the weights I was able to do. And I said, I could just figure out how to do this technically better than maybe I can start breaking that plateau. So that's how I got into it. There's a weightlifting for the gym and weight. You're strong, but you need to work with me and I'll have you lift them more. And I said, okay, challenge accepted. So that's how I got into it. You still have a lot. You feel like you never have a handle on, honestly. So I'm still figuring it out, but it's a way to channel my strength in a more productive way. Yeah, I use the Olympic lifts for like when I was throwing, but I never got, I never technically got good. In fact, I'm technically pretty horrible. I'm just strong. So I can just bull things like a lot of power movements and not very deep catches and ugly. And for me, it's, I just do high pulls and stuff like that in many cases. And I don't need to catch it. I'm not competing or as crossfit. You might be in certainly a Olympic lift and you have to be. So it's a good exercise. Yeah, it would be so technically sound, but also like you have to be able to, I think a lot of people still have crossfit and say, oh, like, why is why Olympic lifting? Like, why does a grandma need to do that? And it's not necessarily the lift, but it's training those neuromuscular patterns to move something a certain way. That's actually really important to harness. And if your grandma can snatch a PVC pipe, I'm much less worried about her falling. Because she's already demonstrating the motor control to do that. So like training those patterns, you end up not really lifting all that much can actually be valuable. Yeah, that is something I'm playing with a lot of plyometric training right now. And it's one of those things where I think it has such a tremendous utility in older population. If you start doing, well, it starts up really early, but even 50s and 60s, I think if you can jump, like, I saw a woman 95 jump in a row and looking good, like she had good rhythms. She's not going to fall on a break or hit. I'm pretty calm, because she can catch herself and she has the capacity, because I cannot tell you how many little old ladies tripped over their damn cat or their dog in their kitchen, and then their life is basically, or yeah, their bones just break. To integrate. Yeah. Yeah, I'm seeing that. I see that in all people. I see that in young girls too. The bones are dust, and you have to build that up because they're just getting any stress fractures and stress injuries and things like that. Yeah, let me go back to the comment you made about. You said women rarely are eating enough protein. What do you see? What populations are you seeing that in? Is it older women? Is it all because you probably are dealing with a lot of older folks? I imagine. Yeah, it's across the board. Also, I'm a team position for a lot of colleges out here, so I'm seeing young female athletes who are coming in with stress injuries, and then that, that covers a whole, it's a whole pandora's box of things of why did that happen? And they're often having muscle dysfunction, and it all goes back to not eating enough, either intentionally or over-training, whether intentionally or not, but finding that energy balance so that they're not having the hormonal derangements and the subsequent bone stress injuries. But I see it, and I see across the board, especially with the college kids, and they're eating all whatever's in the cafeteria, whatever the friends are giving them, whatever garbage is around, and they don't think twice about it. And then you're seeing the manifestations of that in older people, but they just don't eat very much, or they're just, they have no sense of how much protein they're not getting, or they're taking those shakes, those ensure things or whatever, which are all seed oils and sugar with protein, and that's not how to do it either. So, it's, I'd say, a majority of the people I see who are just not eating enough, and don't realize it, really. Yeah, and protein has been vilified for so long, just for various reasons. I know some people are coming around to this and figuring it out, but there's still a pretty anti-protein sentiment in many places, I think. Yeah. Do you find that when you are able to, do you get, how much long term follow-up do you get on your patients? Because I assume it's, do you get to see people over a period of a year, and stuff like that? Oh, yeah, people, I see every three months, and I don't know where they'll see them for their knee this week, and the next week with their shoulder, the week after that is their back. So, I have my regulars for all their aches and things, but, yeah, no, I see people, in general, I tend to see more patients fairly. So, are you using, do you have like physical therapists, occupational therapists at work in and around with you, and under you, perhaps? We have, the health system has affiliated therapy groups, and then in my clinic, I work with an athletic trainer, so she's on site to help with people's exercise plans and things like in the clinic. And then, I also have this network of just people that I've come to know, either through CrossFit or through other means that are like local physical therapists or chiropractors and things that I trust, that if someone demonstrates to me that they want to spend the time, the money, the energy, the effort and fixing something, I got the perfect guy for you, really, he'll get it done. But if someone's, I don't, I guess it's something I really want that, then here we have the kind of insurance-based PTs that do what they do, and they'll help you, too. In your office and your clinic, is there exercise going on in there, or are you coming into an injector? What is your environment? So, for me, it's like, I have, I mostly see, I do shorter consults and we do a lot of injections here, ultrasound-guided injections, so that's a big part of my day, and then I'm assessing, we have X-ray here, people have X-rays, then I'll do my assessment of them. And then, in certain cases, yeah, people are like, "Okay, you need some gluteal strengthening, and I have my athletic trainer go in and show them some exercises in the visit." Or sometimes people will ask me, "I do get a fair amount of people asking me here, and this is how I do at the gym, what can I do, what can I do, and I can break that down for them, somewhat briefly here." But I do have an athletic trainer who does demonstrate exercises, too, when we need that. So, are you, like, completely referral-based, or do people come see you as a primary intervention, or do you usually get referred to from? Well, you might have people, like, in the gym over here, but, "Hey, I hurt myself, can I come see you?" Yeah, sure. Or, like, someone will send them in from that, or there's, like, a central other primary care doctor send them in, or other orthopedic people will send them in based on what they need. Or people who know that I do a lot of, like, things involved with, like, exercise and strength training and stuff, who they, oh, you should see her. I see that, and I do separate kind of educational, more in-depth, consults through a separate kind of entity. Okay. And what are just in the general popularity of probably so much, but obviously, your orthopedic patients are going to be a little different. Yeah. What are some of the major things interventions you typically see with these are the deficiencies that most people have? I know, I'm sure there's many, but what are some of the common things that you see? Postural weakness. I don't know what it could be. Yeah, a lot of postural stuff. Because everyone's like phones, computers, everyone's like this all day, so then everyone's getting, like, next back pain, shoulder pain from being like this all day. So I see a fair amount of arthritis, but, like, pain burden from arthritis. It's not just, I have arthritis and hurts. It's like the pain is almost a little bit out of proportion, or, like, the amount of function that's being impacted is just a little bit of proportion to the actual I'm seeing on the x-rays. And a lot of that has to do with the metabolic state, but they're in chronic tenonopathies from just chronic inflammation, or, like, mucinous changes and, like, I see a fair amount of, like, people with ACLs that are just, are just falling apart from just years of just not taking care of themselves, frankly. I see a lot of gout, a lot of gout. It's alarming, actually, and almost always I'll say the people who present with gout are also presenting with some, I'll say, cognitive sensations as well, which I think there's definitely a link there between the inflammatory process and the nutrition and cognition and the bigger. Yeah, I'm just adding totally. I'm saying there's definitely something here, but I see a lot of fair amount of gaps. People will go to the emergency room and say, "My knee hurts." And they'll say, "Okay, it's probably worth a panic," and they send them to me, ultimately, and it's, you're chronically inflamed. You've got your riddle just gout. And they'll tell me what they ate the day before, and I'm like, "Oh, boy, this isn't good." So, yeah, I see a fair amount of that. Another, like, mythologic conditions that present, people think it's a, like, a structure problem, and it's actually, like, an inflammatory problem. Yeah, with gout, I, what I took care of gout, it almost always seemed to be someone who was also metabolically compromised, either diabetic, pre-diabetic, metabolic disorder. I think gout is a, it's not just your gas. I think it's a whole cascade of inflammation and immune system dysfunction. I think there's a whole bunch of things that go in there, and so what I see with my gout people is that when they fix their sort of metabolic state, their gout seems to resolve. I don't know your perspective what the uric acid level is doing, but, yeah, I mean, it's, when you see what people are eating, it's because red meat has gotten the blame of gout, and it's probably, you see just as much from fructose and alcohol, and probably more so from those things, right? Honestly, but I think it's more, if you got gout, you'd better check yourself for pre-diabetes and all the other metabolic dysfunction that's going on, for sure. And it's crazy because I, I, I reckon as that, you reckon as that, but in use of probably so many primary care workers are not seeing that, or not making that connection. We'll just check your gas level and say, and often in the acute flare, the blood level is low. So, you know, check the blood levels. Oh, it's fine. You actually don't have got, I'm like, this story's consistent. The, the joint aspect is consistent. It's gout, trust me. Well, the joint aspect is consistent for sure. But it's, I just, I'll take your all-appearn all and whatever. And that's the list of things, yeah, list of things that people are taking. So, it's the polypharmacy is conditional. So do you, as someone who, again, I don't know how the insurance works around this, but if somebody comes in for you to say, "I've got knee pain," and you want to, and you look at them and say, "Look, there's probably some metabolic issues here," and you would work that up with XYZ laboratory tech. Is that, do you ever get a hard time about that day? Do you have to go and, you know, ask for pre-authorization because this isn't covered under knee pain and blah, blah, blah. So, yeah, I can get pretty tricky. Certainly with a lot of times, what I'll do if I really want to do an extensive workup is I'll basically just say, "You just see your PCP and get these things," and we'll all send a note to the PCP saying, "I think they should get these things." Now, how often that actually happens? Like, the person actually goes and gets the follow-up and it happens, not always. But something like an A1C, for example, we actually, because of this research that's going on, we're able to get an A1C machine for the office, which took a lot. But because it's under a research project, now we have that ability to try to check it on site. So, something like that, you see PFI was just doing. I think you touched on, like, trigger fingers and stuff. And there's clearly a correlation between trigger fingers and diabetes. What kind of things are you seeing present as orthopedic problems, and you go, "Hey, I bet you're A1C's up," and how often do you find it to be the case and what are the things you see? Yeah, trigger fingers, chronic tendinopathy. So, a lot of these rotator tendinopathys that if I find someone's not making an athlete, they're not someone who I would say, "You should have this kind of all the time." And for sure, I used to have capsulitis as another big one, suffros and shoulders, pretty much almost always. A lot like these tendinopathy, yeah. All of those tendinapophes and these apophes that are just like these kind of indole kind of thing. And then, certainly like when I see those gap peaks, like these inflammatory arthritis looking things that seem to me a little bit off. Anytime I see a mucin, it's a change of a ligament, a lot of the kind of the light is even. If someone doesn't have a story that is consistent with a lot of categories, I'm looking at that. Even some like low back pain people, if I get, I have an MRI in an X-ray that's like not, doesn't really have a smoking diet, I'm saying, "Mm, something else is here." All those things. And almost always, there is a correlation, there's something there. So, carpal tunnel, like you were saying, the other one. Dequervance is another one. It's almost everything. I see all the things I see because I'm not seeing a lot of like acute traumas. So, I'm seeing all these like kind of chronic things that I'm saying, there's something here. Yeah, I'm in one particular diagnosis in orthopo, we used to hate saying it was patella tendonitis because it's like, it's not really operative, you put camera in there. And it was just a lingering thing. There's a rehab you would do. But I suspect, because that often presents in younger athletes, I suspect there's probably a metabolic component to that too. So, I don't know if you see that with patella tendonitis in your younger folks, but I would guess, I don't know. And the patella tendonitis, often there's like a lot of the tele femoral issue, which is a lot of like udial strength and stuff like that. So, that's usually the issue is the udial strength and just having not a lot of motor control at that area. So, I see that more in the younger people. Let's talk about, let's talk about gluteal strength. That's one of my favorite topic I enjoyed talking about. People don't realize that. The reason we can stand upright as humans is because we have these big gluteal muscles. That's what they do. They give us upright. And I think a lot of people, like you see these older people, like particularly old men in their butt, it's like a pancake. And then you see their walking speed is really low. So, how about the glutes? How important are they? How do we effectively keep them robust and strong? And a lot of people like strong glutes. I spent a lot of my time talking about butts actually, so especially for women. So, yeah, your gluteal muscles, they serve many important functions, but especially a lot of the pain syndrome that I see. So, they stabilize, stabilize your hips, stabilize your little back, it also stabilizes essentially how your femur track. So, preventing that kind of valgus moment at the knees. So, that can also affect knee pain. People with knee pain and hip pain, back pain, often it's all at least centrally related to gluteal strength. And a lot of times, it's a really simple thing I'll ask people to do. Can you stand on one leg? And you'd be surprised how many people can't do that for any, like, significant amount of, like, for five, ten seconds. And a lot of times, people say, "Ah, I have bad balance." And I'm like, "Nah, nah." So, unless you've had a stroke or you have some kind of, like, inner ear problem, it's not a balance issue. It's a strength issue. You can't stabilize yourself on one leg without going like this. Right? And then, if you can do that, can you squat on that leg? Can you do a single leg squat? Even if it's half depth, can you, without your knee tracking in, without your body kind of caving in? And most people cannot do that. And I see fairly strong people, too, not strong. And then you test their glutes in isolation. Your glute, their glute needs in particular in isolation. And it's pretty weak. Or even people with really strong legs tend to be quad dominant, and their glutes are turned off. Especially, like, when you think about running, for example, and I see a lot of runners pee pain, back pain, et cetera. Like, running is a series of single leg squatting. You're landing on one leg, and essentially in a sort of a half squat every time. So, if your butt isn't strong, it's not holding you up, preventing your hips from tilting, preventing your knees from caving in. Ultimately, imagine you do that thousands of times while you're running. You're going to, something's going to hurt by the time you finish. So, so I see a lot of that. So, and older people who just, their butt's disintegrated and turned off, or younger people who aren't really activating them. So, it's been a lot of time talking about that here. What are, for those people that are interested in having a stronger butt, what are some of the more effective things people can do at home? Maybe they don't have a gym membership or something like that. So, squatting, super important. Squatting, making sure you're, while you ascend, you push your knees outward. That's really important. Or anything on one leg, so lunging, or like a split squat. Even if you're doing like a, sort of like a pistol single leg squat, but you're lowering yourself to a chair, sitting in the chair and then getting back up. Instead of, that's a way to do it supported, or like tying a band to a pole and holding that while you do it so it pulls you up. But really focusing on that single leg stuff, and like it should hurt, like your butt should hurt when you finish. Another thing to test, a lot of, when, I find even clinicians do this incorrectly as far as testing boot strength. So, it's not just hip abduction, it's hip abduction and extension, and that's your rotation of the femur. So, if you test somebody's abduction strength and just have them push like moderately out against your hand, most people are pretty strong in that direction. When you have them push out and then back a little bit, you can break a lot of people that way. So, it's so, I tell people when they're exercising, if you're doing like clam shells or whatever it is, or kicks, you have to make sure you're kicking out to the side, but also behind you, because that's really important. And also side to side movement. So, those muscles are really important in your side to side movement. And as people, we don't move side to side very often. We're always going in this direction, like running, biking, walking. So, practice moving laterally, the bands on around your legs, you could do that, and these monster walks as they're called, because that can also activate those muscles. Yeah, fair enough. Interesting. Let me ask you, you're obviously practicing, you're doing your crossfit. I guess you've got some relationships and some other ventures that you're doing. What things are you like planning for the future if you have anything? Do you think that this is what I'd like to do? And why do you just keep pressing what you're doing? There's the day job, which is the stuff, the clinic stuff. But yeah, I know I've actually worked out a book talking about a lot of this stuff with metabolic health and orthopedics injury and injury prevention. And people have been talking about this in other respects. Like, Chris Palmer has done an amazing job with the psychiatric piece of this. Orthopedic space is still kind of like a theater key as well. And Casey Means' book, the orthopedic part is like a scope paragraph, a chapter or like a half a page. And it's like, there's so much to it. And I'm biased in thinking that the muscle cell system is the most important one. It's the biggest organ system in our body, so it behooses us to take care of it. Yeah, so working on that, we'd like to just talk more about this kind of stuff and bring more of the forefoot. Every time I'm at a conference, there's always like a few orthopedics. I'm like, hey, I'm interested in that too. We should form a group. Hopefully we can do more formally organized as the fetus who are interested in the metabolic side of it. So that would be cool to get that more formally in selling. Yeah, I know there's several orthopedic guys that sort of participated in my social media. They're getting that. And I think that as much as we talk about heart and lungs and the cardiovascular system and how important it is, but you can't develop that if you're chassis. If your car and your wheels are broke flat, you're not going anywhere. So you've got to make sure you've got the rest of the body that can propel those things. And that's, I think, often a secondary consideration. And like I realized as an orthopedic surgeon, the reason I went into orthopedics is I was like, I don't have to worry about all this chronic disease, crap. Just give me a broken bone or a torn ACL. I can fix it. That was cool. But then I come to realize that all the arthritis and tendon, and opathy, and carpal tunnel syndrome, all the stuff I was operating on in many cases, was just lifestyle, chronic metabolic disease, manifesting as orthopedic complications. And I think that's something that is clearly not discussed enough in the work. Because I'm trying to be a surgeon. It doesn't do many kinds of things. It's interesting. Like looking at the surgeons is saying, you might not care about it, but your outcomes would be better. Your surgical outcomes would be better if the person going into the surgery is a better condition. So if you cannot think about nothing else, then at least that role of field to those people. So yeah, I think that's, there's a place where there's a need for it. I think at this point, we can't ignore it. So yeah, doing that. And then other than that, like I said, since for patients who are either not local to hear or who have questions that are a little more in depth than what my normal 15-minute office visits would be, then I do some with some education, essentially. People want to talk about that as well. That's outside of your group, right? That's outside of your health system, right? Yeah. So it's technically not like medical care. It's education. It's something called best-in-class MD. You can find me on there and just like a little visit. And that is a frustration I saw as a physician. And I think most people, even if you want to do the right thing, you know, I had enormous resources to get me to the operating room. I had labs. I had radiology. I had clinic facilities. I had the OR itself, which is a hugely expensive thing to run. And for me to do a lifestyle intervention, I had no resources. This wasn't supported. And I think that's a thing that even in your own clinic, you've got to go outside and develop your own thing, which is, I think that's a real falling of the medical system. Because if you had a, I can, I suspect more people would do it if they had the resources directly to it. But again, it's how to make that. Cost-effective and profitable unfortunately. It's not incentive us. You know, it's not. So that's important. It's not incentivized at all. No. Even something like, I was pushing to get like an in-body scanner for our in-body scale. It does body composition and all that. I know that would be such an eye-opener for so many patients who think they're in good shape or will tell me that you healthy and tell me the exercise I need to look at. I'm going to say, I don't know if that's true. You say, here's your body, 5% or cheers. Your visual back to be able to, again, it's her health system and stuff like that. Okay. What's the money on the back end and all that. To me, it's just the right thing to do. Do you, I know you mentioned that if you have the audacity to tell a patient they need to lose weight and you get all kinds of negative reviews. Oh, yeah. I can remember that. I remember I had a lady that came into me and she wanted, she wanted like her bazillionth cortisone injection. And I said, look, you really have to address the underlying cause for this. And I'm not inclined to give you one of these injections today. She stormed out of the office, complained. I got a complaint about me not being, just handing out injections left or right. And she, and they rescheduled with somebody else who did it. I was like, come on. This is really kind of productive in the long term. But how many, if you were to say, just looking at body composition, how much of a correlation between sort of suboptimal body composition, maybe sarcopenia, maybe too much obesity, is correlated with these orthopedic issues that you're seeing. Do you see that higher in those populations? Most, almost always. Yes. Yeah. It's almost 100%. It's almost a linear relationship from what I say. Or just the amount of pain that someone experiences from the same condition. There's a body composition piece of it. And then I also see it a lot with just someone's baseline activity. Like someone who's like a regular exerciser with that person is able to deal with physically is almost always way, way more than what you would necessarily expect sometimes. Yeah. So it's got to be hard, hard enough. Yeah. That's something that it's, it is quite interesting that I would see people's x-rays. And you'd see some kind of lean old farmer that's been like busting his ass for 50, 60 years. And his x-ray looks awful. And you ask about his knee pain and be like, oh, yeah, it hurts a little bit. Right. You know, it wasn't. And then you'd see someone who's just clearly never done anything. They're, they're sedentary obese. And their x-rays look damn near perfect. With just a tiny little bit of arthritis. And they're in their howling. Oh my. This is my every day. Yeah. Yeah. Yeah. It's crazy that it's like the, sometimes people are like terrible, say, so terrible arthritis who are just people who've been active in their life. And yeah, it hurts a little bit. I'm like, how are you walking? I'm like surprised. And I usually tell those people, I know you're just keep up doing what you're doing. Because that's why you're able to do being dysfunctional right now. And it's amazing to me that sometimes if those people end up in a different place, then I'll basically be told that the doctor can tell them, yeah, you have stenosis. You shouldn't exercise anymore. You shouldn't do that anymore because the stenosis you have. And like at the same time, that exercises what's keeping that stenosis from being told disabling. And so I go, ah, listen, don't listen to that advice. I think I have an x-ray in my whole body. I'd be scared to be honest. I'm sure I've got torn men, this guy and degenerative spinal. I'm sure it's in me, but it doesn't limit me any significant way because I just get after. I think the second I stop training regularly and hard, my quality life will go down very quickly. I'm sure. So I just have to keep it up. Yeah. And like, I think also that's too, that's my attitude about it. And sometimes we'll have this musical terror. I'm like, okay. And you're going to stop living now so that that attitude surprises people. They're like, yeah, me too. Yeah, me too. Yeah, me too. And then I did lift it yesterday. It's a little bit of that kind of, okay, your life's not over. Let's keep going. Yeah. Whenever you hear somebody telling you how many bulging discs they have, I'm always like, oh, come on. I'm like, I got 12 bulging. You're like, okay. So just sort of half the population probably. Right. And it's like, you have to research age. You just gotta keep moving to an extent. Be smart about it, but you gotta keep moving. Yeah. I think that's it. I think keep moving, stay strong, stop eating garbage. It's a boring but effective message that, like I said, people just, they want the magic, whatever. And they like it out of time. Yeah. So anyway, we'll go. This is awesome. And then we'll finish up. The last thing I was going to say is there's a lady that I know who goes through. She's in her 60s, 70s almost. And we're at CrossFit. And she had this kind of like weird accent. She like slipped off the pull-up box. She was doing pull-ups. Okay. This lady was in her 70s doing pull-ups. And she like slipped. And she was like, "Oh my God, this seven-year-old lady fell off from a height, oh no." And I basically said, "You're lucky because nothing, there was no severe damage. Because you're in such good shape, a fall like this. You really didn't have, you're lucky. You didn't have to fracture. You're actually, you're gonna be fine." But the end result of that conversation was that the doctor said, "Yeah, but you shouldn't have to look how dangerous it is." And I go, "And that's the thing I see often." You can say from that, "Yeah." So she fell off a pull-up bar, which I guess she wouldn't have been doing otherwise. And she heard herself. But because she had done that regularly, this fall was essentially a non-issue. I could have killed somebody her age. Had she not been in such good shape. And I think that's the conclusion that should be drawn from that. Not that what. That's not, that's a frustrating thing. And I see a lot of medical advice coming out like that. Yeah, and I remember when I was taking trauma, when we were taking general surgery, trauma call, they would, and they would activate the trauma team if somebody felt, if they were a certain age and they fell from, from any sort of height, from two feet. They would like, the trauma team's gotta be activated because these people sometimes they whack their head, they have brain bleeds, they have great, all kinds of bones, because they're so, they're made out of glass, basically. They're like dropping into a little light bulb. Anyway. Yeah. All right. Amy, where can people find you on social media and anywhere else you want to share where you're located? At, at Amy, at Amy West MD, on Instagram, on X, Best in Class MD. You can find me on there by searching my name. I'm also in Amy West MD dot com, coming soon. And I'm also, I practice right now at Northwell Health in New York. It's your local to various. Okay. Awesome. Thank you very much. Awesome.
