Musculoskeletal Manifestations of Obesity

Dr. Fathi Neana, MD
Chief of Orthopaedics
Dr. Fakhry and Algarzaie Hospital
Saudi Arabia
July, 13 - 2017
Obesity
in orthopedics
and trauma
surgery

Systemic disorders and musculoskeletal manifestations
are interrelated
Diagnosed systemic disorders
We expect musculoskeletal manifestations
Vs
Undiagnosed systemic disorders
Musculoskeletal manifestations will guide us to the hidden systemic
disorder
Countless sources of information
Plain X-rays can tell a lot
Even the lifestyle and food selection can help in future expectations
Musculoskeletal manifestation of
systemic disorders

Lifestyle diseases
Non-communicable diseases
(NCDs)
• Obesity
• Coronary artery disease
• Diabetes type 2
• Hypertension
• Arteriosclerosis
• Stroke
• Cancer
• Depression - anxiety
• Arthritis
• Osteoporosis
• Swimmer's ear – loss of hearing
• Ch. obstructive pulmonary
disease
• Liver Cirrhosis
• Nephritis
• Etc, etc, etc…
Emerged as bigger killers than infectious
or hereditary ones
The leading cause of death in the world
63% of all annual deaths
> 38 million people are killed /year
1- Cardiovascular diseases (17.5 million)
Complications of hypertension (9.4
million)
2- Cancers (8.2 million)
3- Respiratory diseases (4 million)
4- Diabetes (1.5 million
These 4 diseases account for 80 % of all
NCDs deaths (> 38 million)

• Stress-Depression
• Diet
• Sleep-awake
• Lack of Exercise
Part 1 & 2
• Sun avoidance
• Wireless WiFi devices
• Leaky gut syndrome
(increased intestinal permeability)
• Other pollutants
• Obesity
• Coronary artery disease
• Diabetes type 2
• Hypertension
• Arteriosclerosis
• Stroke
• Cancer
• Depression - anxiety
• Arthritis
• Osteoporosis
• Swimmer's ear – loss of hearing
• Ch. obstructive pulmonary
disease
• Liver Cirrhosis
• Nephritis
• Etc, etc, etc…
Lifestyle diseases
Non-communicable diseases (NCDs)

Prevent rather than treating Risk factors
Rule of Diet and Exercise

Diagnosed Obesity in the US: 1994 -2008

Adult obesity – UK %
0
10
20
30
40
50
60
70
1980 1997
Male
Female
Overweight % Obese %
0
2
4
6
8
10
12
14
16
18
20
1980 1997
Male
Female

Rise in Childhood Obesity - UK
0
5
10
15
20
25
1989 1998
Overweight
Obese
Bundred et al, BMJ Feb 2001

Misconceptions about
Obesity
1- The soft tissue cushion protect against injuries
2- Bone density is better with Obesity
3- Obesity is simply a biomechanical problem
4- Keep the ball is in your court

1- Select types of musculoskeletal injuries
2- High-energy trauma ->> mortality rates are higher
3- Low-energy trauma ->> they have a tendency to
A- Comminuted fractures
with skin & soft tissues injuries (distal end of long bones)
B- Knee dislocations
with a high rate of neurovascular complications
4- MVA ->> relative protection in abdominal & pelvic injuries
because of their soft tissues. However, more likely to have
A- Pelvic ring injury (energy absorbed by the abdomen is transferred to the pelvis)
B- Fracture peripheral structures (distal femur, ankle, calcaneus and degloving injuries )
Misconceptions about Obesity

What control the Osteoblast activity
1- Need for calcium in the extracellular fluid
2- Mechanical stresses on the bone tissue
3- Growth factors
4- Hormones (Estrogen vs PTH)
5- Cytokines
1- Bone remodeling process (Osteoblast vs Osteoclast)
2- Osteoblast control the activity of the Osteoclast
3- What control the Osteoblast activity?
4- Rule of estrogen ?
The ratio of OPG : RANKL will determine
the extent of bone resorption
Estrogen vs PTH

The ratio of OPG : RANKL will
determine the extent of bone
resorption
Estrogen vs PTH

1- It was initially thought that obese patients had higher absolute bone density,
(Extra gonadal oestrogen ?)
2- When the values were adjusted to the lower BMI in the control group patients,
the increase in the overall bone density is not enough to compensate for the
excess loads placed on the skeleton, especially during falls
3- After menopause, obese women take more falls than non-obese , however
fewer proximal femur fractures, due to soft tissue cushion around the proximal
femur
4- Vitamin D deficiency is more common in Obese (sun barrier)
5- Research is now how leptin could prevent osteoporosis and even replace
oestrogen

1- Not only simply just an excessive mechanical
loads or a physical problem complicating
imaging, surgical approaches, procedures and
skin healing
2- A clear link has been established between
osteoarthritis and obesity, due to the biological
effects of adipokines on cartilage (hand OA)
3-The obesity effect (excessive mechanical loads)
is more apparent in the knee than the hip

1- Recently : Rule of Biochemical processes and Chronic
Inflammation
2- Adipokines (fat-derived hormones)
Leptin (pro-inflammatory)
Adiponectines (anti-inflammatory)
Biochemical processes that trigger osteoarthritis
3- Other series of pro-inflammatory and anti-inflammatory
agents that are increased in obesity
Inflammatory cascade involves interleukins (namely IL-6, TNF-
alpha and IL-12) that trigger osteoarthritis
4- Clinical studies have shown relationships between
adipokines levels and cartilage volume loss

Obesity musculoskeletal
manifestations
Pathogenesis
1- Biomechanical
problem
due to excessive physical
loads
2- Biochemical processes
& low grade chronic
inflammation
3- New specific antibody-
based drugs to control
the negative effects of
adipokines

1- Recent meta-analysis only 14–49% of patients had lost a significant amount of
weight 1 year after Arthroplasty surgery
2- Do not expect weight loss after surgery, It is more logical to ask patients to
lose weight before the surgery to reduce the magnitude of symptoms.
But this weight loss is often difficult to achieve, even when the patient is surrounded by a team of
nutritionists and endocrinologists
3- Is there is a need to have them undergo bariatric surgery before the
Arthroplasty
TKA before bariatric surgery, TKA within 2 years after bariatric surgery, and TKA at least 2 years after
bariatric surgery in patients having maintained their initial weight loss.
4- The authors concluded that the complication rate was elevated in all three groups and that none
of the three solutions were ideal,
even if the patient had lost weight due to the bariatric surgery, maintained the weight loss and the
metabolic adaptation period had passed

Metabolic Bariatric Surgery (MBS)
Intermittent Fasting (IF)
LCHF Diet (MMT-KD)
+
Regular Exercise
(Walking & Running
vs Sustained Resistance Exercise)
‫وتعالى‬ ‫تبارك‬ ‫الحق‬ ‫يقول‬:‫ى‬َّ‫ت‬َ‫ح‬ ٍ‫م‬ ْ‫و‬َ‫ق‬ِ‫ب‬ ‫ا‬َ‫م‬ ُ‫ر‬ِ‫ي‬َ‫غ‬ُ‫ي‬ ‫ال‬ َ َّ‫اَّلل‬ َّ‫ن‬ِ‫إ‬ْ‫م‬ِ‫ه‬ِ‫س‬ُ‫ف‬‫ن‬َ‫أ‬ِ‫ب‬ ‫ا‬َ‫م‬ ‫وا‬ُ‫ر‬ِ‫ي‬َ‫غ‬ُ‫ي‬
[‫الرعد‬:11]
H. albassam

Obesity musculoskeletal manifestations
Pathogenesis
1- Biomechanical problem
due to excessive physical loads
2- Biochemical processes
& low grade chronic inflammation
1- Osteoarthritis is more common with obesity
2- Involving non weight bearing structures ( Hand OA)
New specific antibody-based drugs
to control the negative effects of adipokines

Medical Complications of Obesity

Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancer
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Gout
Medical Complications of Obesity
Idiopathic intracranial
hypertension
Stroke
Cataracts
Severe pancreatitis

Definition of Obesity
Excessive weight that may impair health
• How do we measure If
someone is obese?
– Body Mass Index
BMI = Weight (kg) / Height
squared (m )2
– Waist to Height ratio
WHtR = Waist (inches) / Height
(inches)

– Normal weight = 18.5-24.9
– Overweight = 25-29.9
– Obesity = 30 or greater
Body Mass Index BMI Categories
BMI = Weight (kg) / Height squared (m )2

WHO classification of obesity
BMI = weight(kg)/height(m)2
WHO Classification BMI Risk of Death
Underweight Below 18.5 Low
Healthy weight 18.5-24.9 Average
Overweight (grade 1 obesity) 25.0-29.9 Mild increase
Obese (grade 2 obesity) 30.0-39.0 Moderate/severe
Morbid/severe obesity(grade 3) 40.0 and above Very severe
World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO, 1997
[3]

Waist to Height ratio
WHtR = Waist (inches) / Height (inches)

Causes of Obesity
1- Was thought to be the result of (too much energy in and too little
energy out)
2- The actual causes are more complex: a combination of
Genetics, Activity level, Diet, Endocrine, Drugs,
Environmental and Nutritional factors

Heterogeneous distribution of adipose tissue
and risks of metabolic and cardiovascular
complications
Visceral vs. subcutaneous
obesity
Gender differences
Differences in risk for
complications
Dyslipidemia, type 2 diabetes, hypertension, coronary heart disease, …
Nature. 2006 444:881-7
The apple The pear

Musculoskeletal Manifestations of Obesity
Childhood obesity
Damage the growth plate
Early arthritis
Risk for broken bones
Fractures and Related Complications
Slipped capital femoral epiphysis
Blount's disease
Painful flat Feet
Impaired Mobility
Developmental coordination disorder
(DCD)
Anesthesia Complications
Surgical Treatment Complications
Adult obesity
OA (knee, hip, hand)
Low Back Pain
Diffuse idiopathic skeletal
hyperostosis (DISH)
Gait disturbance
Soft tissue conditions (for example,
carpal tunnel syndrome, plantar
fasciitis)
Osteoporosis ?
Gout
Fibromyalgia
Connective tissue disorders
(rheumatoid)

Childhood Obesity
Impact on bone, joint & muscle health

Over the past 20 years, a dramatic increase in the
number of children, adolescents and adults diagnosed
as overweight or obese in the United States
Today, approximately 32% of American children and
adolescents, ages 2 to 19, are considered overweight or
obese
Childhood Obesity

1- Environmental factors include:
• Availability of less healthy foods and sugary drinks.
•Advertising of less healthy foods.
•Lack of daily, quality physical activity in schools.
•No safe and appealing place, in many communities, to play or be active.
•Limited access to healthy, affordable foods.
•Increasing portion sizes.
•Lack of breast feeding support.
•Greater exposure to television and media.
U.S. children ages 8 to 18 spend an average of 7.5 hours a day using entertainment media
including TV, computers, video games, cell phones and movies.
2- Other conditions or diseases include:
Hypothyroidism, Cushing's syndrome, Prader-Willi syndrome and Kleinefelter's
syndrome
Courtesy Thinkstock ©2014
What Causes Childhood Obesity?

1- Non skeletal hazards
•High blood pressure and high cholesterol, both of which are risk factors for
cardiovascular disease.
•Increased risk of impaired glucose tolerance, insulin resistance and type 2
diabetes.
•Breathing problems such as sleep apnea and asthma.
•Liver disease, gallstones and gastro-esophageal reflux.
•A greater risk of social and psychological problems.
2- Skeletal hazards
Too much weight also can seriously impact the growth and health of bones, joints,
and muscles. Damage the growth plate – Early arthritis - Risk for broken bones -
Other serious conditions, such as slipped capital femoral epiphysis and Blount's
disease.
Childhood Obesity
and Musculoskeletal Health

Slipped Capital Femoral Epiphysis
Courtesy of John Killian, MD, Birmingham, AL
Develops during periods of accelerated growth or shortly after the onset of puberty
Hormonal dysfunction associated with obesity may alter growth plate function
Extra weight also increase the sheer forces across the proximal femoral growth plate
Treatment of SCFE
Within 24 to 48 hours of diagnosis
Stabilizing the "slipped" growth plate with a screw to prevent further slippage
In children with obesity, it can be more challenging to position and secure the head of the
femur without complications.
(SCFE) is an orthopaedic disorder of the adolescent hip
The head of the femur slips off in a backward direction due to
weakness of the growth plate
Cause weeks or months of hip or knee pain, an intermittent
limp 0r In severe cases, the adolescent may be unable to bear
any weight

Slipped Capital Femoral Epiphysis

Blount's Disease
Severe bowing of the legs
Hormonal changes and increased stress on a growth
plate
Irregular growth and rogressive deformity, rather
than knee discomfort
In younger children and less severe cases, a leg brace
or orthotic may correct the problem
Surgery, tibial osteotomy, may be needed
obese have a higher risk of complications related to
this procedure, including infection, delayed bone
healing, failure of fixation, and recurrence of Blount's
disease

Fractures and Related
Complications
Obese or overweight have a higher risk for
fractures due to:
1- stress on the bones
2- weakened bones secondary to inactivity
3- More complications that can delay or alter
treatment outcomes
For example
1- Traditional metal implants may not be
sufficiently strong
2- crutches may be difficult to use
3- cast immobilization may not sufficiently
stabilize broken bones
3- surgery, in addition to casting, is often
required

Children who are overweight or obese often
have painful flat feet
Tire easily prevent them from walking long
distances
Many are treated with orthotics and stretching
exercises focused on the Achilles tendon
Weight loss to ease the pain
low impact weight reduction exercises, such as
swimming
Painful flat Feet

Impaired Mobility
Developmental coordination disorder (DCD)

Difficulties with their coordination
Developmental coordination disorder (DCD)
The symptoms of DCD may include:
•Clumsiness
•Problems with gross motor coordination such as jumping,
hopping or standing on one foot
•Problems with visual or fine motor coordination, such as writing,
using scissors, tying shoelaces or tapping one finger to another
•DCD may impair or limit a child's ability to exercise, potentially
resulting in more weight gain. Physical and occupational therapy
may improve DCD.
Impaired Mobility
Developmental coordination disorder
(DCD)

Higher rate of anesthetic complications
than normal-weight children
likely to have diabetes, hypertension, sleep
apnea, and other endocrine abnormalities
that may affect surgical and other
treatment
Delay or impair bone healing and a return
to normal function.
Anesthesia and Other Surgical Treatment
Complications

In a very small number of children with extremely high BMIs — 40
or above — bariatric surgery may be recommended
Reduce weight and avoid long-term musculoskeletal and other
related conditions and complications.
In most children, a diet rich in calcium and other nutrients, along
with regular, physical activity — at least 35 to 60 minutes a day-can
help
minimize weight gain, while helping to build and maintain strong
bones.
For more healthy lifestyle and fitness tips for children: Fitness for Kids
Preventing and Treating Weight Gain in
Children and Adolescents

Fat bloke my arse
Adulthood Obesity

International Journal of Obesity (2008) 32, 211–222; doi:10.1038/sj.ijo.0803715; published online 11 September 2007. The impact of obesity on the
musculoskeletal system. A Anandacoomarasamy1, I Caterson2, P Sambrook1, M Fransen3 and L March1
Adulthood Obesity
Fat bloke my arse
Obesity is associated with a range of disabling musculoskeletal conditions in
adults.
As the prevalence of obesity increases, the societal burden of these chronic
musculosketelal conditions, in terms of disability, health-related quality of life,
and health-care costs, also increases.
Research exploring the nature and strength of the associations between obesity
and musculoskeletal conditions is accumulating, providing a better
understanding of underlying mechanisms.
Weight reduction is important in ameliorating some of the manifestations of
musculoskeletal disease and improving function
.

Musculoskeletal conditions associated with
Obesity
OA (knee, hip, hand)
Low Back Pain
Diffuse idiopathic skeletal hyperostosis - DISH
Gait disturbance
Soft tissue conditions (example, carpal tunnel syndrome,
plantar fasciitis)
Osteoporosis
Gout
Fibromyalgia
Connective tissue disorders (example, rheumatoid
arthritis)

OA is the most common form of arthritis
Leading cause of chronic disability among
older people
Obesity is a risk factor for the development
and progression of tibio-femoral knee OA
(both symptomatic and radiographic)
Obesity associated with OA at other sites
such as hip, hand and patello-femoral joint
Both mechanical and metabolic factors may
be responsible for the link between OA and
Obesity.
Osteoarthritis

Obesity is an independent risk factor for incident
radiographic OA.
Increased weight initiates a pathway of cartilage
degeneration prior to the emergence of OA symptoms
Radiographic severity in those with varus malalignment
Overweight is associated with increase in cartilage turnover
biomarkers. Cartilage oligomeric matrix protein and
collagen type 2 degradation products
Increased muscle mass was also associated with a reduction
in the rate of loss of both medial and lateral tibial cartilage
volume
This study shows that increasing BMI may induce cartilage
defects even in those with no radiographic OA.
Knee osteoarthritis

Obesity was more closely associated with
bilateral hip OA than with unilateral hip OA
A systematic review found moderate
evidence for a positive association between
obesity and the occurrence of hip OA
The associations between obesity and hip OA
were stronger when the diagnosis included
clinical as well as radiological criteria
There is currently no accurate data on the number of obese patients getting hip or knee arthroplasty in
France. Of the 480 total hip and 420 total knee replacements performed by three senior surgeons in
our department in 2012, 40% of patients were overweight, 20% were obese and 5% were morbidly
obese.
Hip osteoarthritis

In a large Finnish study, BMI was found to be directly
proportional to the prevalence of thumb carpo-metacarpal OA
in both sexes
In the recent Rotterdam study, overweight showed a significant
association with hand OA independent of other metabolic
factors
Leptin may have an important role in the metabolic influence of
overweight on OA. Serum
leptin, the product of the obese (ob) gene, is involved in energy
regulation at the level of the hypothalamus and recent evidence
suggests that leptin may act locally in joint tissues.50
Leptin has been detected in synovial fluid samples obtained
from OA patients and levels of leptin have been found to
correlate with BMI.51 Leptin has also been strongly
overexpressed in human OA cartilage and in osteophytes.
Hand osteoarthritis

The need for joint replacement surgery has been escalating with the increased burden of
OA in the community.
In Australia over a third of all total hip and knee replacements are performed in the obese
in the United Kingdom knee replacement in the obese (BMI >30) are probably comparable
to the non-obese but larger, prospective studies are needed to ascertain long-term
outcomes.
However, outcomes in the morbidly obese (BMI >40) are consistently poor.9
Similar data are not available for the effect of morbid obesity in hip replacement.
Obesity not a contraindication to simultaneous bilateral total knee replacement surgery.70
However, a BMI >32 predicted failure in those undergoing minimally invasive medial
unicompartmental knee arthroplasty in a retrospective series.71
Obesity is a risk factor for patients undergoing high tibial osteotomy for the treatment of
unicompartmental knee OA in the presence of malalignment.72
Outcomes relating to quality of life and satisfaction following arthroscopic debridement of
the knee were also poorer in overweight women than the normal weight group.73
Surgery and anesthesia

Low back pain from degenerative disc disease of the
lumbar spine, spinal canal stenosis and zygo-apophyseal
joint disease
More likely to have radicular pain and neurologic signs
Bariatric surgery, weight loss significantly improved.
Spinal epidural lipomatosis is also associated with
obesity
Hypertrophy of the epidural adipose tissue, causing a
narrowing of the spinal canal and compression of neural
structures.
Outcomes of sciatica , obesity was associated with
adverse 6-month outcomes
Obese is also a risk factor for postoperative meralgia
paraesthetica after posterior thoracolumbar surgery
However, outcome assessment in elderly patients
undergoing lumbar spinal surgery did not find any
difference in the obese group suggesting that surgery in
the elderly obese with appropriate symptoms would be
reasonable.90
Low back pain

(DISH) or Forestier's disease, a chronic age-related condition
New bone growth especially at the entheses. affects many
skeletal structures but typically the thoracic spine.
It is associated with obesity, diabetes mellitus, hyperinsulinemia
and hyperlipidemia
Serum leptin levels were significantly elevated
Leptin may be genetically and indirectly associated with the
pathogenesis of the ossification of spinal ligaments in female
patients.
The role of obesity in the pathogenesis of DISH is yet to be clearly
defined and the effect of weight reduction in reversing/slowing
progression of disease has not been studied.
Diffuse idiopathic skeletal hyperostosis
DISH

Obesity is associated with structural and functional limitations
Impairment of normal gait, flattening of the foot arches and pronation of the
ankles
Obesity increases rearfoot motion during walking and causes the forefoot to abduct more
than in normal weight individuals
Excess weight is associated with increases in the amount of force across a weight-bearing
joint
Inadequate postural instability as measured by time of balance maintenance and
medial-lateral sway of the trunk.propensity of overweight individuals to fall while
performing everyday activities.
Attenuated dynamic balance performance. Poorer balance was found to be associated
with higher pain scores in t he presence of weaker knees.
Morbidly obese subjects also walk significantly slower than their obese and lean
counterparts
BMI was one of the factors affecting the variance in walking distance
Gait disturbance

Obesity is consistently a significant risk factor for pain in the neck (10–19%), shoulder (18–26%),
elbow (8–12%) and wrist/hand (9–17%) at any given time
Prospective cohort study over 5 years . Obesity predict those who develop upper extremity
tendonitis associated with work activity. Another prospective survey Obesity increased the risk of
ulnar entrapment at the elbow
A recent study painful musculosketelal conditions in obese before and after weight loss following
bariatric surgery. There was a significant decrease in pain at most sites following weight loss and
physical activity after 6–12 months, in particular the cervical and lumbar spine, and foot.
Large case–control study using the UK General Practice Database. Obesity was a significant risk
factor associated with carpal tunnel syndrome
An association between obesity and shoulder repair surgery for rotator cuff. Increasing BMI is a risk
factor for rotator cuff tendonitis and related conditions
Plantar fasciitis. Obesity is a risk factor for developing unilateral plantar fasciitis. Obesity is also
associated with chronic plantar heel pain. Arch biomechanics are thought to play a role in etiology
but this has not been conclusive.
Obesity is also a risk factor for trochanteric bursitis, a frequent cause of lateral hip pain in middle-
aged and elderly individuals.
Soft tissue complaints

1- The amount of adipose tissue, the major site of conversion of androgens to estrogen in both elderly men and
women. This explain why the effect of weight is greater in women than men. why shortly after menopause, obese
women do not lose bone as rapidly as their non-obese counterparts.
2- Increased mechanical load that heavier individuals place on weight-bearing bones. This is supported by some data
suggesting that body size is a better determinant in weight bearing rather than non-weight-bearing sites.123
Although it is considered that obese subjects are at lower risk of osteoporosis, changes in bone marrow fat with
ageing may adversely affect skeletal strength. Visceral fat may have a protective effect on BMD through biochemical
factors such as adiponectin. an adipocyte-derived hormone that regulates insulin sensitivity and energy homeostasis.
However, recent research suggests that obesity may accelerate bone loss.131 Deng et al. showed, in two large
population samples, that the bone strengthening effects of a heavy body were not due to fat but to elevated muscle
mass, which increases bone density. The authors report that increased fat mass is associated with decreased bone
mass,
Postmenopausal women may be more susceptible to bone loss with weight reduction. Weight loss due to caloric
restriction appears to induce rapid bone loss unlike exercise-induced weight loss.
The rapid increase in obesity has led to an escalation in the uptake of surgical techniques to control weight.
Procedures that involve duodenal bypassing place individuals at risk for osteoporosis as this is the primary site for
calcium absorption. Obesity is also a risk factor for vitamin D deficiency.
Osteoporosis and vitamin D deficiency
A number of studies have demonstrated that body weight is closely correlated with bone mineral
density (BMD). In cross-sectional studies, a 10 kg increase in body weight is associated with
approximately a 1% increase in BMD. This relationship has been demonstrated for both women
and men and across cultures but the effect of weight on BMD appears to be stronger in women
than in men, and more in postmenopausal than premenopausal women.

Gout is the most common form of crystal -induced
arthritis (deposition of monosodium urate crystals). In
USA affects more than 1% of adults
Obesity is a well-known modifiable risk factor in the
pathogenesis of gout. Serum uric acid is positively
associated with BMI
The size of the visceral fat area is the strongest
contributor to elevated serum uric acid concentration,
decreased uric acid clearance and increased urinary uric
acid/creatinine ratio
Weight loss is advocated in the overall management of
gout but no study has assessed the effect of weight
reduction on uric acid levels or attacks of gout
Gout

Fibromyalgia is a complex disorder resulting in pain,
disturbed sleep and altered mood
A number of risk factors are associated with this
condition and obesity plays a role
In a pilot study of overweight and obese women
with fibromyalgia
Relationship between BMI and fibromyalgia symptoms were
assessed after a 20-week behavioral weight loss treatment
Participants lost, on average, 4.4% of their initial weight
Weight loss predicted a reduction in fibromyalgia
symptoms, pain interference, body satisfaction and quality
of life.
In a study of obese subjects undergoing bariatric
surgery, there was a significant reduction in
fibromyalgia syndrome at follow-up 6–12 months
later
Fibromyalgia

Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disease. Obesity has
been identified as a risk factor for RA. The association appears to be a threshold effect with no
relationship between BMI and the risk for RA below a BMI of 30.
Paradoxically, one study in a cohort of 779 RA patients found that BMI was inversely associated with
mortality independent of methotrexate use. BMI was protective only if the erythrocyte
sedimentation rate was low.150
Obesity recently found to be independently associated with impaired quality of life in patients with
RA.151 A marked increase in plasma levels of adipocytokines (leptin, adiponectin and visfastin) have
been noted in patients with RA suggesting a role in the modulation of the inflammatory
environment in these patients.152
In systemic lupus erythematosus, obesity is a strong predictor of preeclampsia.153 Obesity is
common in the lupus population, 36% prevalence in one urban university clinic.154 However, obesity
was not associated with hypertension and diabetes in this cohort and contrary to expectation,
overweight systemic lupus erythematosus patients appeared to register the highest quality of life on
questioning.
Hypoandrogenicity in males is common in obesity and in chronic inflammatory conditions such as
systemic lupus erythematosus and RA.155 Leptin, as well reflecting adipose tissue mass, is stimulated
by tumor necrosis factor and is associated with hypoandrogenicity in non-inflammatory conditions.
Leptin has been found to correlate negatively with adrenal androgen concentrations in patients with
systemic lupus erythematosus and RA, suggesting that leptin may be an important link between
chronic inflammation and the hypo androgenic state.155
Connective tissue disorders

Beyond the mortality and the respiratory and thromboembolic
events . Infection is the main problem in Obesity & DM
A study with 7181 TKA and THA patients
1- increase infection rate from 0.57% in normal to 4.66% in morbid obesity
2- Diabetes doubled the infection rate, independent of the presence of
obesity
3- In patients with morbid obesity and diabetes the infection rate was 10%
The authors questioned whether it was justified to operate on these
patients. But it seems of the utmost importance not to operate on these
patients unless the diabetes in completely under control
The patient information step must include this infection risk, which
is relatively higher than in patients with a normal BMI. Since this
risk is correlated to diabetes . Diabetes must be well controlled and
managed during the entire perioperative period
Infection risk

10 articles were published in English and the time of publication varied from 2006 to 2014. The
tendinopathies analyzed were: rotator cuff, patellar, medial and lateral epicondylitis, Achilles, trigger
finger, posterior tibial, peroneal tendons, plantar fascia and pes anserinus. The type of studies was
case control and cross sectional (some of them involving population)
Results:
The pathogenesis of tendinopathies includes inflammatory, regenerative and degenerative processes
that happen simultaneously. Mechanical stress upon tendons seems to be one of the most important
factors to initiate the inflammatory response, but it´s not the only one that can deflagrate it: there are
other extrinsic, genetic and metabolic factors that may be involved.
Tendinopathies in obese due to 1- tendon overload because of the excess of weight
2- increased production of pro-inflammatory mediators related to fat tissue such as adipokines.
This pro-inflammatory state that obese people can suffer is known as adiposopathy, or sick fat
syndrome. Weight loss is associated with decrease in adipokines and improvement of musculoskeletal
symptoms.
Conclusion:
The relation of obesity and tendinopathies is supported by evidences of recent studies,
exemplified in this review of literature.
Tendinopathies and tendon tears account for over 30% of all musculoskeletal
consultations. Obesity, which is becoming one of the world´s most prevalent public health
issues, may be associated with this condition.
Relation of obesity and tendinopathies
supported by evidences of recent studies

Relation of obesity and tendinopathies
supported by evidences of recent studies

Benefits of 10% weight loss
Mortality >20% fall in total mortality
>30% fall in diabetes related deaths
>40% fall in obesity related deaths
Blood pressure fall of 10mmHg systolic and diastolic
pressure
Diabetes 50% fall in fasting glucose
Lipids 10% dec. total cholesterol
15% dec. in LDL
30% dec. in triglycerides
8% inc. in HDL
Jung 1997

Mortality >20% fall in total
mortality
>30% fall in diabetes
related deaths
>40% fall in obesity
related deaths
Blood pressure fall of 10mmHg
systolic and diastolic
pressure
Diabetes 50% fall in fasting
glucose
Lipids 10% dec. total
cholesterol
15% dec. in LDL
30% dec. in
triglycerides
8% inc. in HDL
Jung 1997
Intermittent Fasting IF
Bariatric surgery
Very low carb Diet Regime
Exercise
Each patient is a rule for
himself
Benefits of 10% weight loss

Safely Fasting for Weight
Loss

Musculoskeletal Manifestations of Obesity

Musculoskeletal Manifestations of Obesity

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