The key is to have the patient buy in and take ownership

1. The Intersection of Plant-Based
Nutrition with
Sports and Spine Medicine
Stephan Esser MD

2. Disclosures
• None

3. My Practice Setting
• Multi-Physician Private Practice: 20-35 pt’s /day (6000/yr)
• Ages: 10-Grave
• Body Regions: All
• Offerings: Evaluations, PT/Personalized Ex/ Ultrasound Diagnosis
and guided injections, PRP, Stem Cell Injections, Acupuncture etc
-Lectures/Weekly-Day long Retreats/Online..more
• Team Physician: University of North Florida Athletics
• Other: Clinical Faculty at Mayo Clinic and St Vincent’s Family
Medicine Residency and Brooks Institute of Higher Learning

4. Goals
• Review common pathology subsets seen in an
“Orthopedic” setting
• Evaluate the cross roads of plant based
nutrition and MSK care
• Identify 5 principles of care
• Review Cases
• Strategize application to your clinical setting

5. Esser’s Health
Ranch
Dr William Esser ND, DC 1911-2003

6. Challenges
• Patient Goals/Expectations
• Clinicians Goals
• Application / Time / Reimbursement

7. Orthopedic Complaints
• Pain
• Loss of Function
• Alteration in Performance
• Rarely “prevention”

8. Orthopedic Complaints
• Pain
– Anatomic
• eg: Fracture, Ligament tears, Tumors, Large Disc bulges
– Biomechanical
• eg: Body Weight, Weak hips/Glutes, Hypertonic Hip
flexors, Weak Scapular stabilizers, Sarcopenia
– Physiologic
• Biochemical/Cellular or Neurophysiologic

9. Highest Yield
Biochemical + Biomechanical

10. Biomechanical
• Weight
• Muscle Balance
• Ligament Flexibility
• Lean Muscle Mass
• Limb Lengths/Postural Issues etc

11. Physiologic
• Cellular Inflammation
– Arachidonic Acid and Prostaglandins
– Generalized Cytokine Release
– Absence of “Anti-oxidant rich” foods
– Inflammatory Joint Problems: Gout,
Rheumatologic disease
– Impaired Perfusion
– Visceral Fat: Adipokines

12. Arachidonic Acid
https://epi.grants.cancer.gov/diet/foodsources/fatty_acids/table4.html

13. Cytokine Release
• Diet influences Cytokine Release
– Fruit and Vegetable Intake reduce levels of Pro-Inflammatory Cytokines Root, M et al. Combined
Fruit and Vegetable Intake Is Correlated with Improved Inflammatory and Oxidant Status from a
Cross-Sectional Study in a Community Setting Nutrients 2012, 4(1), 29-41

14. • Cellular Inflammation
– Arachidonic Acid and Prostaglandins
– Generalized Cytokine Release
– Absence of “Anti-oxidant rich” foods
– Inflammatory Joint Problems: Gout,
Rheumatologic disease
– Impaired Perfusion
– Visceral Fat: Adipokines

15. Rheumatology
• Inflammatory/Autoimmune Conditions
– “Leaky Gut” Hypothesis
– Tissue Mimicry
– Excess Purines leads to excess Uric Acid
• 27 patients were allocated to a four-week stay at a health farm. After an initial 7-10 day subtotal fast, they were put on an individually
adjusted gluten-free vegan diet for 3·5 months. improvement in number of tender joints, Ritchie's articular index, number of swollen
joints, pain score, duration of morning stiffness, grip strength, erythrocyte sedimentation rate, C-reactive protein, white blood cell
count, and a health assessment questionnaire score Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis
Lancet 1991
• A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction
in antibodies to food antigens Rheumatology 2001
• 4-week, very low-fat (~10%), vegan diet on 24 free-living subjects with RA, average age, 56 ± 11 years old. All measures of RA
symptomatology decreased significantly (p < 0.05), except for duration of morning stiffness (p > 0.05). Weight also decreased
significantly (p < 0.001). At 4 weeks, C-reactive protein decreased 16% (ns, p > 0.05), RA factor decreased 10% (ns, p > 0.05), while
erythrocyte sedimentation rate was unchanged (p > 0.05). Effects of a Very Low-Fat, Vegan Diet in Subjects with Rheumatoid Arthritis
The Journal of Alternative and Complementary Medicine 2004

16. Perfusion
• Blood Flow is essential for
– performance, healing, function, prevention
• High Fat/High Cholesterol meals
– Impair vascular dilation
– Produce Fatty streaks, CVD precursors
– Impair blood flow to MSK tissues
– Reduce O2 and micronutrient delivery
– Alter regional pH

17. Perfusion
• High Total Fat, High Saturated Fat, High
Refined sugar meals inhibit blood flow and
arterial dilatation
– Effect of a Single High-Fat Meal on Endothelial Function in Healthy Subjects single high-fat
meal transiently impairs endothelial function by up to 50% at 4 hrs after the meal AJC 1997
• Minimally Processed, Plant-Based Foods have
vasodilatory effect
– Flavonoid-rich apples and nitrate-rich spinach augment nitric oxide status and improve endothelial function in healthy men and women: a
randomized controlled trial Free Radical Biology and Medicine 2012
– An increase in F&Vs, regardless of flavonoid content in the groups as a whole, mitigated increases in vascular stiffness measured by PWA (P =
0.0065) and reductions in NO (P = 0.0299) in the control group Flavonoid-rich fruit and vegetables improve microvascular reactivity and
inflammatory status in men at risk of cardiovascular disease—FLAVURS: a randomized controlled trial AJCR 2014
– In healthy overweight and slightly obese men a single dose of beetroot juice attenuates the postprandial impairment of FMD following a
mixed meal, possibly through increases in plasma NO concentrations. Beetroot juice improves in overweight and slightly obese men
postprandial endothelial function after consumption of a mixed meal Athersclerosis 2013

18. Perfusion
• Spinal Degeneration and Impaired Perfusion
• Aortic Calcifications as a risk for back pain
– Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a person's risk for
development of disc degeneration and is associated with the occurrence of back pain. Disc Degeneration/Back Pain and
Calcification of the Abdominal Aorta: A 25-Year Follow-Up Study in Framingham Spine 1997
– A significant association is indicated between atheromatous lesions in the abdominal aorta and low back pain. Association of
Atherosclerosis with Low Back Pain and the Degree of Disc Degeneration Spine 1999
– Aortic atherosclerosis and stenosis of the feeding arteries of the lumbar spine were associated with DD and LBP.
Atherosclerosis and Disc Degeneration/Low-Back Pain – A Systematic Review EJVES 2009
– High serum lipids predicted incident radiating LBP, consistent with the atherosclerosis-LBP hypothesis. Serum Lipids and Low
Back Pain: An Association?: A Follow-up Study of a Working Population Sample Spine 2006

19. Perfusion/Cholesterol
• Serum Lipids and risk of Rotator Cuff Tear
– Impaired micro-perfusion
– Increased risk of injury
– Increased risk of re-tear and slowed healing
• Patients with rotator cuff tears were more likely to have hypercholesterolemia when compared with the control
group.
• The Effect of Hypercholesterolemia on Rotator Cuff Disease Clinical Orthopedics and Related Research 2010
• Dyslipidemia may decrease the improvement of patient-reported outcomes in
• patients undergoing treatment for RCTs; high triglycerides and low HDL may have
• the most impact.The effect of lipid levels on patient-reported outcomes in patients
• with rotator cuff tears JSES Open Access 2017 The present study found a significant
• association between moderate and high perioperative total cholesterol and LDL
• levels and the rate of revision surgery after primary arthros copic rotator cuff
• repair. Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery
• Rate After Arthroscopic Rotator Cuff Repair AJSM 2017

20. Perfusion/Increased Cholesterol
• Achilles Tendon Rupture
– Impaired healing
– Increased risk of tear/re-tear
• Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) concentrations of the patients with ATR were
higher (p<0.001), and their high-density lipoprotein cholesterol (HDL-C) was lower than the control group (p<0.05).
Moreover, the concentrations of triglyceride (TG) and very low-density lipoprotein cholesterol (VLDL-C) were
significantly higher than controls (p<0.05). Is high concentration of serum lipids a risk factor for Achilles tendon
rupture?
• People with altered tendon structure or tendon pain had significantly higher total cholesterol, low-density lipoprotein
cholesterol and triglycerides, as well as lower high-density lipoprotein cholesterol. Is higher serum cholesterol
associated with altered tendon structure or tendon pain? A systematic review BJSM 2015
• One intrinsic factor that appears to have an association with tendinopathy is body composition; more specifically central
adiposity Adiposity and tendinopathy Disability and Rehabilitation 2008

21. Perfusion
• Healing
– Impaired perfusion
• Increased risk of infection
• Impaired healing
– Pre and Post Surgery

22. Biomechanical
• Weight:
– Lower Extremity Joints
• 1lb above the waist = 3-10 below
– Upper Extremity Joints
• Inc. Weight = Inc. work for RTC, neck muscles
– Alters Spinal Mechanics
• Inc. Lumbar Lordosis and “facet based pain”
• Inc. Risk of Spinal Stenosis

23. Weight and Plants
• Vegetarian diets are associated with reduced body weight, lower incidence of
certain chronic disease, and lower medical costs compared with non-
vegetarian diets Vegetarian Diets and Weight Status Nutrition Reviews 2006.
• Self-identified semivegetarian, lactovegetarian, and vegan women have a
lower risk of overweight and obesity than do omnivorous women. The advice
to consume more plant foods and less animal products may help individuals
control their weight. Risk of overweight and obesity among semivegetarian,
lactovegetarian, and vegan women American Journal of Clinical Nutrition
2005
• The 5-unit BMI difference between vegans and nonvegetarians indicates a
substantial potential of vegetarianism to protect against obesity. Increased
conformity to vegetarian diets protected against risk of type 2 diabetes after
lifestyle characteristics and BMI were taken into account. Pesco- and semi-
vegetarian diets afforded intermediate protection. Type of Vegetarian Diet,
Body Weight, and Prevalence of Type 2 Diabetes Diabetes Care 2009

24. Weight and Joints
• Don’t leave the “snow on the roof too long”

25. Weight and Joint OA
• Obesity is a primary risk factor for disease onset, and mechanical factors increased the risk for
disease progression. Moreover, inflammatory mediators, in particular, adipose tissue-derived
cytokines (better known as adipokines) play a critical role linking obesity and osteoarthritis
Biomechanics, obesity, and osteoarthritis. The role of adipokines: When the levee breaks Journal of
Orthopedic Research, 2017
• Obesity enhances the cross-talk between chondrocytes and synovial fibroblasts via raised levels of
the pro-inflammatory adipokine leptin, leading to greater production of IL-6 in OA patients. IL-6
secretion in osteoarthritis patients is mediated by chondrocyte-synovial fibroblast cross-talk and is
enhanced by obesity Scientific Reports 2017
• Higher body mass index was associated with an increased risk of hip replacement due to
osteoarthritis (P for trend = 0.0001). Compared with women in the lowest category of body mass
index (<22 kg/m2
), those in the highest category of body mass index (≥35 kg/m2
) had a twofold
increased risk (95% confidence interval [CI]: 1.4 to 2.8), whereas those in the highest category of
body mass index at age 18 years had more than a fivefold increased risk (95% CI: 2.5 to 10.7).
Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable
risk factors The American Journal of Medicine 2003
• Increased weight = increased risk of OA and resultant need for THA and TKA. Role of Obesity on
the Risk for Total Hip or Knee Arthroplasty Clinical orthopedics and Research, 2007
• This underscores the immediate need for greater use of clinical and public health interventions,
especially those that address weight loss and self-management, to reduce the impact of having
knee OA. Lifetime risk of symptomatic knee osteoarthritis Arthritis Care and Research 2008

26. Biomechanical and Biochemical
are Closely Linked

27. Orthopedic Application
• Reduce Pain
– Reduce inflammatory substrate
– Increase anti-inflammatory foods
– Reduce weight and reduce adipokine production
• Improve Perfusion
– Enhance oxygen, nutrition delivery
– Facilitate prevention and Accelerate healing

28. Orthopedic Complaints
• Pain
• Loss of Function
• Alteration in Performance
• Rarely “prevention”

29. 5 Principles of Care
• 1: Evaluate Need and Readiness for change

30. Case
• A 48 y/o female with a BMI of 36 presents
with right knee pain
– PMH: Rt Meniscectomy 2015, Obesity, HTN, HLD,
Depression
– Other: SAD, No exercise habits, Smoking
– Xray:

31. Case
• “Terrible, made unscientific assumptions………….tried to
prescribe a fad diet program.………………Once again, should
not be a licensed physician.”
• Need was real, Readiness was absent
• I failed her

32. Case
• A 56 y/o male presents to clinic walking with
crutches due to severe knee pain. Knees are
swollen, painful to move at all. Labs show
highly elevated serum uric acid levels.
– Plan: Standard discussed, patient requests
alternative (agrees to 1 week juicing, 3 week
plant-based detox)
– Follow up: 3 weeks with update
Need was real, Readiness was present
Uric Acid 9---0.9
ESR 30----2
Lawn
Need was real, Readiness was present
Uric Acid 9---0.9
ESR 30----2
Lawn

33. Identify
• “Knock on doors”
– Tired of Medications
– Frustrated by weight
– Chronic Pain
– Chronic inflammation
– Search…….

34. • 2: Determine clinically the extent of change
needed to result in the effect desired

35. Case
• A 62 y/o female tennis player with right
shoulder pain presents for evaluation
– PMH: None Ex: 6 days per week
– Medx: None Nutrition: Plant Based 10 yrs
• A 62 y/o female tennis player with right
shoulder pain presents for evaluation
– PMH: HTN, HLD, Obese Ex: 3 days per week
– Medx: Statin, Metoprolol Nutrition: SAD

36. Case
• A 48 y/o male desk employee presents with
right shoulder pain
– PMH: Obesity ( BMI 83), HTN, Metabolic
Syndrome, Depression
– Clinical Exam: Suggests Full thickness RTC tear

37. • 3: Develop a “plan of care”

38. Case
• A 72 y/o male presents with low back pain.
– PMH: HTN, HLD, Psoriasis, Obesity, Hand OA
– Xrays: Aortic Calcifications noted
• Patient comments he is tired of his 5 medx.
• Plan: Offered PT and a 4 week plant based
“detox”
• At 6 weeks, 30lbs lighter, off all BP medx,
Psoriasis resolved, back pain 60% improved,
resizing wedding ring to fit fingers

39. Case
• A 54 y/o male with advanced knee OA
presents to discuss stem cell treatment
– PMH: HTN, HLD, Obese
– Plan: 4 week plant based “detox,” Pool swimming
– Results: 28lbs weight loss, Knee pain 75%
improved
– Plan: PRP injections and continued knee PT

40. Plan
• Offered by the clinician
• Accepted by the patient
• Facilitated by……
– Patient, Spouse, Child, Friend, Dietician, etc
• Plant Based Nutrition
– Primary Intervention or 2ndary Intervention

41. • 4: Track outcomes

42. Tracking
• What will you track?
– Pain, Performance, Labs, Weight ?
• Patient self tracks
• Regular follow up clinical visits with review of data
• Are your goals the same as the patient’s goals?

43. Case
• 65 y/o male with bilateral leg numbness and
burning and knee pain and foot drop
– PMH: S/p spinal surgery, Borderline T2D, HTN, HLD
– Plan:
• Reduce inflammation thru 4 week Plant-based detox
• Add in high dose B vitamins, Omega 3, Inositol, Mag. G.
• Continue PT, Follow up on all recent films, labs, EMG
• Provide AFO for foot drop
– Follow Up
• Foot Drop Unchanged
• 24lbs weight loss, Stopped 1 BP, 60% reduction in leg pain

44. • Caution

45. • 5: Modify accordingly

46. Outcomes
• Complete Improvement
• Partial Improvement
• No Gains

47. Application
• Develop Relationship
• Identify “need”
• Determine “readiness for change”
• Provide knowledge, resources, encouragement
• Follow up closely
• Evaluate success
• Modify plan of care accordingly

48. Plan
• There are multiple levels of intersection
where plant based nutrition and MSK care
overlap
• Plant Based Nutrition can
– Reduce Pain
– Reduce Inflammation/Swelling/Edema
– Reduce Weight/Alter Biomechanics
– Improve Perfusion and Nutrition delivery
– Reduce “disease” risk

49. Plan
• Learn the “Science” of the condition treated
• Learn the “Science” of plant-based nutrition
• Identify when/where/if they intersect
• Learn to “Market” this approach
• Track/share outcomes
• Modify / Adapt

50. Conclusion
• The “Needs of the patient come first”
• Sometimes Love/Empathy/Compassion are
the first need
• Circle of Influence/Creative/Collaborative
• Never lose your enthusiasm/joy for the
message or for people

51. “There’s a book, Profound Simplicity, that has
nothing to do with health, but this is exactly
what this system is—profound simplicity. It is
profound in that it holds the truth in all its
splendor within itself and still it is so simple
that unfortunately most people are
unimpressed by the truth.”
Dr. William Esser ND
NH Keynote Address 1980

52. Thank You!
Stephan Esser MD, USPTA