The Future of Joint Pain Treatment Starts Here

We have 18 seconds to dance, people. Come on! We can loop it. We can get 36 seconds of dancing. Sabrina, are we doing it again? Okay, one more time. Sabrina Carpenter, thank you for all you do for men. We appreciate you calling our bullshit. All right, all right, that's good. We can be good. Whoo! Thank you guys so much for having me here. It's not every day that an orthopedic surgeon gets to come talk to actual smart people, so I really do appreciate Good morning, everybody in the room. I'm so excited. And when Donna said, hey, come be on this Symposium at Sea, I thought, oh great, we're gonna be on a luxury Viking cruise, there's gonna be like 80 of us. And I showed up and there's like 9,000. And it's a little bit overwhelming. Thank you so much. It's been really cool to see all of the other speakers and I just, I'm learning so much from everyone. But let's get into it. So I wanna talk a little bit about what hormones, what we're all working on can do for musculoskeletal pain, okay? So in my life, it's all about the joint, right? So I've been through this a long time and as I started to look into the functional medicine realm, I started to learn more about how we can actually help people. So I wanna share some of that and some of what we've learned. Why is this so important? Why is musculoskeletal pain so important? Well, the cost of pain, which includes chronic joint pain, exceeds $560 to $630 billion annually. That's a lot of cash, right? That's more than the combined cost of heart disease, cancer, and diabetes altogether. Arthritis specifically, $303 billion, and that's medical expenses like joint replacements and earning losses, all of the all-in. Osteoarthritis by itself, right about 65 million. So what does this tell us? Well, it tells us that there are a lot of people in this country who need help and a lot of them hurt. All right? Joint pain actually turns out to be a systemic disease. Who in here thinks that there's more to joint pain than just the joint? I love this room. Thank you. I do that in an orthopedic surgeon conference and they're like, "What you talk about, bro?" So 19% of adults have some form of arthritis, right? That's some form of joint pain. But 25% of men and women aged 45 report having some arthritis, and that doesn't mean that they have end-stage arthritis, right? Just some joint pain. 88% of OA patients are 45 or older. 70% of adults over 50. Does this sound like anybody's patient avatar? Right? Yeah, we're talking to these people. We're speaking to them every day. So your hormone patients have joint pain, right? 70+ percent of your patient population is experiencing joint pain. That means that you're already working with them. Who in here believes that we're reducing inflammation doing what we do? Whether it's gut, whether it's hormones. Yeah, exactly. So we're already working to balance their hormones, reduce their inflammation, restore their vitality. And what does this mean? That bringing together an idea of joint preservation, joint treatment, with hormone and metabolic optimization gives our patients the opportunity to live longer, better lives. We can help people live better by treating their knee pain. That's pretty novel. In orthopedics. There's a disclaimer. I don't know why it's on there. Here's my objective. So first, I wanna talk a little bit about what we do in orthopedics. What's the traditional approach to joint pain? Oh, goodness. And we wanna review some of the key hormones. Not gonna talk about everything. There's lots of complicated pieces that fit into joint pain, but I wanna really cone in on the sex hormones 'cause they're really cool. I want to discuss the integration of how metabolic optimization and what we do in regenerative medicine can kind of come together and make for better results for our patients. This is the northern portion of Italy. It's Venezia. It's the foothills of the Alps. I fly paragliders. You can see me. I'm the little guy right by the A. That's what I like to do. So who am I? Well, I'm a board-certified orthopedic surgeon. I've performed more than 15,000 surgeries in my career. I was hired by a small hospital in Wichita Falls, Texas in 2007, and I quickly became the director of orthopedics. I was the director of orthopedics there for about a decade. I ran an orthopedic center of excellence for hip and knee replacement. And so we did thousands and thousands of joint replacements, and as we started, as I continued in my career, what I noticed was, one, It was getting busier and busier, and I was getting paid less and less. And then two, it was getting busier and busier, and we were paying less and less attention to patients' health needs. So that when I started, when I tried to start an initiative, hey, how can we improve our outcomes? How can we reduce our complications? How about we check hemoglobin A1C? They're like, well, what if it delays surgery? You want your patients to quit smoking? What if it delays surgery? So the hospital administrator started to weigh in on that a little bit. And as we're trying to get healthier and healthier patients in the door, and we're trying to put some parameters and put some safety bumpers on what we were doing, we were getting more and more pushback. Anybody else experience that in their medical career? Yes, preach. Everybody preach about that. It's wrong, right? Guys, I know that I look like an orthopedic surgeon, but I have more than a hammer, and my patients are more than a nail, right? They might need a socket wrench. That's my other tool. Why I'm actually here is because of this beautiful woman sitting in the front row, Amber. This is us in Egypt. That is the Sphinx. It's not CGI. That's actually the Sphinx. It's a beautiful place. This is the love of my life. I've been with Amber since I was 17 years old. Yeah, thank you. Thank you, that's very kind. Oh, you derailed me. So this woman is very special to me. We've been married for 29 years, and at the age of 32, we received a diagnosis of BRCA1. Everybody knows what that is? That's bad shit, right? And so at the age of 33, she entered surgical menopause. She had 5 surgeries in 11 months. And I had to watch my vital, vibrant, beautiful wife sort of collapse into this cave of brain fog and poor motivation, her skin dried up, she didn't wanna have sex, that's a problem, right? But really she felt desperate and she felt like she didn't have any options. And when she went to her oncologist and said, I feel like crap. I don't really wanna live this way. And I'm reading about hormone replacement therapy and you never talked to me about it. Can I get some hormones? What did her oncologist say? Oh no, you can't do that. You'll die. And she's like, I'm gonna die miserably like this anyway. What about fracture risk? And her oncologist said, do you wanna die now or do you wanna break your hip and die? And she's like, well, that seems like a Kind of a crappy choice. So we looked and we looked and we searched and we found an integrative functional medicine person who was willing to do her hormone replacement therapy. And at the age of 34, she started that process and it's changed her life. And watching her respond to hormone therapy and respond to the strength of these treatments and see the way that it improved her vitality, improved her quality of life, and by the way, she's not dead. She's doing just fine, right? She's strong, she's healthy. Her DEXA scan is that of a 35-year-old. She's doing great. It proved to me in my mind that we have better, we have better ways to use our medical chops than just to pass out a pill and tell people no, right? We got better ways to do that. So we developed a system, and when we went into private practice in '23, we really wanted to look at how do these hormones, how do all of these other systems in the body actually affect joint pain. And so as we were developing our concept at Pinnacle, I wanted to combine regenerative medicine and she wanted to combine hormone replacement therapy and functional medicine. And it's come together to be this beautiful synthesis of what we can do, the potential of what we can do when we combine everything that we know about joint pain. It's really, really cool. But let's talk about how the traditional system is failing patients. So, You come to an orthopedic surgeon, first of all, you get about 15 minutes if you get to see the orthopedic surgeon, right? And then he tells you what? Well, you've got some knee pain. We're gonna start what? What's the first thing we do? [FOREIGN LANGUAGE] That's— you guys are way ahead of me. First thing we do, we should do, first thing we should do is what JJ asked them to do. Let's move around and get strong, right? How's it work? So I'll order physical therapy. Okay, young lady, you come in, we have some knee arthritis. It doesn't look too bad. I'm gonna order you some physical therapy. I'm gonna order 18 sessions, your insurance will pay for 3. You go, right? You go to your first session, physical therapist has 50 other patients to see that day. He goes, okay, move it around. Okay, do some squats. Okay, that hurts, we can't, you're not a candidate. Take this home exercise program, I don't think I can work with you. I saw that over and over and over, and that's a bit of an exaggeration. Our therapists are really wonderful people and they try, but they're stuck in a system. Physiotherapy is designed to fail in traditional orthopedics because why? We wanna do surgery. We do. We wanna do surgery. We wanna do some surgery because we look good in scrubs, right? That's right, that's right. This checkered jacket doesn't look that great. I want scrubs on, people, come on. The next step is we're gonna help you with your pain. So what we're gonna do, we're gonna give you some narcotics. We're gonna give you a pill. It's gonna make the pain go away. Then we're gonna do some steroids. That's another 1. That's interesting. It's all number 1. And then finally we're gonna do some surgery, right? And maybe between 1 and 1, it's about 4 weeks or 6, 'cause I can't do a knee replacement within 6 weeks of a steroid injection or else you get a horrible infection And then you might actually die, not like with the hormones with Amber, right? The fact of the matter is these are really killing our patients. They're still killing our patients, right? We're doing a lot better with opioids, started to turn around in about 2016. Opioid deaths are down by about 20% since '22, but still, there's about 42 to 46 opioid prescriptions per 100 patients in the United States. Right, isn't that crazy? What is that, what are they getting them for? Well, they're getting them for post-procedure. And if we're doing a lot of procedures, what are we doing? A lot of opioids, right? Rounds out to be about 220 opioid deaths per day. And that doesn't even account for the metabolic effects of narcotics, right? So the next step is a steroid injection. Who in here is taking care of joints? In the mezzanine, anybody? Anybody? Are we doing any steroid injections? A little bit? A ton. Oh gosh, okay. Steroid injections are pretty bad for the joint though, do you agree? Not ideal. Not ideal, exactly. That's orthopedic speak for they're pretty bad, but we don't have a great alternative, so I'm gonna just do this 'cause it feels good. Steroid injections make me feel really good. They make you feel really good too, right? 'Cause we give you a steroid injection, that person's like, "Oh, my knee feels great." I'm gonna get on out of here. You know, we have a very positive experience. Unfortunately, when we put that steroid in the joint, it forms little crystals, it damages cartilage surfaces. We put it into a tendon, it damages that tendon, sometimes chronically, sometimes irreparably. And if we do it around a rotator cuff tear or something like that, then it can make that tear much worse and make it very difficult to heal, whether we do regenerative therapies or whether we do surgery. Is that correct, right? Yeah, exactly, exactly. So steroid injections, I feel, are the devil. I don't do them anymore. I do regenerative therapy instead. And if we have a viable alternative, why aren't we using it, right? Not every pain needs a surgery. So this is the final common pathway. This is what we wanna get people into. And in orthopedic surgery, you're gonna go see your orthopedic surgeon, 90% of us are gonna say, well, "you're either not ready for surgery, come back when you are," "I don't have another alternative," or "your insurance won't pay for anything else," right? So we end up with a lot of unnecessary joint replacements and surgical interventions. This is from orthopedic literature. As many as 35% of joint replacements done per year are, are what we would call premature, which means that the joint is not actually ready for a joint replacement. We're not in stage. We haven't tried everything. And what does that mean? That means that we've had a 200% increase in joint replacements since the early 2000s in the age group of 45 to 60. Does that sound like our— somebody's patient avatar, right? So we're seeing an increased amount of joint replacements in our patient population, and that's leading to— costs us about $8.3 billion a year. Joint replacements in young patients are about 8 times more likely to have a problem. It's usually an infection, which is very costly, both to the patient and to the system. So this is a problem, right? Does that sound good? It didn't sound great to us either. So when we developed our new— when we developed our programs, when I left the hospital and when I started to be able to think for myself, we wanted to consider this more deeply. So we started to think, what are some of the factors that lead to joint pain, right? We know it's weight, we know age, we know mileage is a problem, we know there's structural issues, but what about metabolic issues? And so when I started to look into the literature, when I started to learn more about what we do, started to learn how powerful the impact of our hormones really are on our joints. And so here's our approach, we call it the Pinnacle Method. It's really pretty revolutionary. It's integrative orthopedics. And so what we wanna look at is we wanna investigate the root cause of pain. So we don't just look at the joint, we look at everything. Then we utilize regenerative techniques. So we use PRP, stem cell therapies. I'll use just about anything to get the joint healing, shy of a steroid. And then we wanna rebuild, optimize, and we wanna restore that patient. So we wanna support them for the long term. And we start with a root cause analysis, right? Just like everybody in this room does. Anything we're looking at, we want to look at sort of a comprehensive approach. So we do a full joint evaluation. I do ultrasound. We look at X-rays. We look at MRIs. And then we dig in metabolically. We go all the way to sleep metrics. Very, very important. All of these things are critical in looking at why a patient actually has joint pain and what makes their pain worse, right? It turns out that there's more than meets the eye, right? Transformers. I love these guys. Anybody else love Transformers? Yeah, the '80s, man. Best cartoons ever. So it turns out when we think about it, hormones are actually critical for joint longevity. There's many recent studies that have sort of highlighted the pivotal role. We look at, you know, they've looked at Cut bowel and testosterone's effect on cut bowel, it increases the effect of healing in the GI system. Estrogen, growth hormone, insulin-like growth factor, cortisol suppression, all of these things matter for joint pain. Everybody knows this graph, right? So in women, we have this sharp decrease in sex hormone production, and that's called menopause. In men, it's much more gradual, but it's just as impactful. Right? So in men and women, when we have declines in our sex hormones, we start to see more joint pain. How many people in this room see patients with joint pain and low hormones? Anybody? Anybody not? Anybody have somebody coming in and just like, "My estrogen's in the toilet. I have horrible brain fog, but my joints feel great." No, that doesn't happen. So it really does impact, and we're also seeing a significant decrease in sex hormones overall, right? We know that men have had about a 20% decrease in testosterone levels on average from the 1980s to the early 2000s, right? It's 18%, it's crazy, right? And then we're seeing it in younger women too. So we see a general decrease in hormones over both sexes. And so this is becoming a bigger problem. It's got many names. This is a busy slide. I like this last one. These were all supposed to, like, have pop-ups, and there was, like, animation, and I think there was even, like, a little unicorn that popped up on this one. But anyway, that last one, musculoskeletal syndrome of menopause, I love Vonda Wright for that one. She explains it so succinctly. But there are so many different labels, and it all really means the same thing, right? So let's talk a little bit about the hormones themselves. The joint itself is hormone receptive, but so are the tissues around the joint, right? So estrogen and progesterone deficiency is very strongly associated with this postmenopausal joint pain. We've known since— all number ones again, okay, great. Where do you see the AI-generated pictures? It's gonna be awesome. We know that these two hormones in particular are very important, and their deficiency leads to a lot of cartilage degradation, synovial inflammation, and subchondral bone loss. Progesterone is a really interesting one. It's not a super prime mover in the joint itself. Think of it more as a central hormone. Progesterone actually does support some of the structural properties of the joint. Ligaments by supporting type 1 collagen growth, but it's also profoundly anti-inflammatory, right? We do give progesterone for pain. It helps to suppress pro-inflammatory cytokines, IL-6, tumor necrosis factor, centrally, and downregulates their genetic expression. So I think that's pretty cool. I think that's the main function of progesterone, although there's not a whole lot of research in this. Estrogen is the bone health machine, right? We know that estrogen improves bone health, right? What's the best medication for bone quality? Estrogen reduces our risk of overall hip fracture by up to almost 40% if we start estrogen in a menopausal woman. That's pretty big, that's pretty big data. I have— it's the best alternative that we have to bisphosphonates. I have seen patients who've been on bisphosphonates for a decade, and I'm doing surgery on them and I can push my thumb through their femur. It's gross, right? So it's not working. So estrogen is the best medication for this. How does it work? Well, it inhibits the resorption of bone by binding to receptors on the osteoclasts, which are the cells that take up bone, and it promotes bone formation by enhancing the activities of the cells that make bone. And then it also helps us maintain the microarchitecture. Why is that important for a joint? Well, because if we don't have good structural support around a joint, then the joint collapses and we end up with deformity, right? Deformity progresses, the pain gets worse. Estrogen and tendon health. Well, estrogen is extremely important for the compliance of our tendons. It keeps our tendons nice and supple. It keeps them stretchy. So it increases type 1 collagen, reduces stiffness, and probably improves tendon healing overall. This last, like, failure to load, we know that high estrogen levels cause increased risk of, like, ACL injuries in young girls, right, in 16-year-old girls. But it also probably protects us as we age from having ligament tears and damage in our ligaments. So we do see people who have low sex hormones have a higher risk of joint injury. Has anybody seen that? Like, I try and get working out and I just keep hurting myself. Yeah, yeah, that's probably why. Estrogen has massive effects in the joint itself. It's very anti-inflammatory, so it regulates that immune response and inhibits the same inflammatory markers, IL-6, tumor necrosis factor, in the cascade. And then it also helps us maintain the extracellular matrix of the cells of the cartilage itself. And then finally, there are actual estrogen receptors in the lining of a joint. And that lining of a joint will actually secrete the joint fluid. And so estrogen helps us maintain our synovial fluid lubrication. So estrogen is kind of like the oil, kind of like the grease of our joints. I— what is that thing in the middle? I entered this into ChatGPT. Show me the benefits of testosterone and joint health. I gave it all these things. And it gave me like a penis with arms. I don't even know if that's actually testosterone, the molecule, but I love it. So thank you, ChatGPT. It makes it fun. At least we're having a good time. So testosterone has anabolic effects. We know that testosterone is probably the most important hormone on muscle for sure. But did you guys know that it actually has massive effect on bone? Isn't that cool? I geeked out on that. It's really cool. So we know that in both men and women, deficiency will add to atrophy, right? We have increased joint stress and progression. Why do we have increased joint stress? Because JJ taught us that muscle quality is extremely important, and the stronger we are across the joint, the better it's supported, the less joint stress we have, right? So mechanisms of testosterone loss and joint pain, we get muscle loss and joint instability, reduced collagen synthesis, we get increased inflammation, and then we have compromised structure. This is one of my favorite one of my favorite studies, came out in 2025. It's a correlation between low testosterone levels and the risk of osteoarthritis, and they did this cross-sectional evaluation. What's really neat is, one, they found that low levels of testosterone in men and in women have a higher risk of progression of arthritic change in the joint. And then they found that participants with OA were more likely to be female and have low testosterone, which I thought was interesting. In April of 2025, they also came out with a study that sort of linked levels in the male of testosterone lower than 300 with progression of arthritis. So in our clinic, we always aim— if somebody's below 300, it's kind of an emergency for their joints. Testosterone is anabolic, right? It supports protein synthesis, it reduces degradation of those proteins, it also activates those satellite cells that we see in the— oh, that's not it— activates satellite cells in the muscles and improves hypertrophy. It makes the muscle larger. And it makes the muscle stronger, right? Then it also promotes ECM components and suppresses inflammatory cascades. Is anybody seeing a pattern in how these sex hormones are working on the inflammatory cascade? Right? They're suppressing all of the same factors. I think that's really fascinating. I wanna learn more about that. Here's what's really cool about testosterone in my world. It does support bone health. It's a secondary one. Estrogen's definitely the best, but look, testosterone will stimulate bone formation. It stimulates osteoblasts. Bone does have testosterone receptors. It also reduces bone resorption by stimulating those cells or inhibiting those cells that take up bone, and then it suppresses that inflammatory cascade like we've talked about. But it's also a bit of a two-for-one. So did anybody think that aromatization might have an upside? Right? So when we're converting testosterone to estradiol, some of that is actually stimulating bone formation. So I'm gonna argue that maybe some of that aromatization can be a positive, right? So cool stuff. So summing that up, estrogen, we can think of it supports that cartilage surface integrity. It reduces stiffness of the tendons and the structures around the joint and improves bone quality and synovial homeostasis. Progesterone really supports cartilage health, but centrally reduces inflammation. And then testosterone enhances musculoskeletal health and regenerative capacity. So all very, very important. So this is— I like this one. What are we looking at here? So we have an engine, we got 3 superheroes. Testosterone looks really manly, but that I think it's great. So progesterone's kind of inhibiting, estrogen's lubricating, that's great. Graphic. But beyond sex hormones, there's at least 4 other major anabolic hormones that directly affect our joint health, and that's human growth factor, HGH. Anybody using HGH in their clinics? It's pretty important stuff. Judiciously. Insulin-like growth factor, cortisol, and thyroid hormone. We'll talk about all of those later. But I do wanna have just a word on cortisol. Cortisol is a really interesting one. Short bursts of cortisol will actually be quite beneficial, suppresses that same pro-inflammatory cascade, inhibits COX-2, which is the same enzyme that Celebrex works on, right? And then also stabilizes the membranes of the cells and then reduces white blood cell migration into a joint. So if you've had a joint injury, then the cells that can damage the joint are not allowed to migrate into the joint itself. But unfortunately, none of us just have enough cortisol. Anybody have too much cortisol? I do. I'm like up here just jazzed all the time. And if you're jazzed all the time, then you get chronic stress and HPA axis dysfunction. And what does that lead to? Chronic inflammatory response, right? We get dysregulation and it leads to this kind of chronic low-grade inflammation that then causes cartilage degeneration. Excess cortisol will accelerate arthritis progression through that cartilage breakdown, right? It revs up the inflammatory cascade. And we know that also imbalanced cortisol is an immune trigger. So all of these things make cortisol a pretty big impactor in how joint pain behaves. And then obviously, if we're stressed out, then we have much more pain. Anybody have a patient do mindfulness and their pain gets better? There's great research to show that mindfulness improves chronic pain. So clearly, bioidentical hormone replacement therapy, metabolic optimization has some great benefits for the musculoskeletal system, right? We enhance bone density, it's best medicine for it. Muscle strength and function, testosterone's number one, right? Reduced inflammation. We can heal cartilage and tissue more optimally, and then improves joint lubrication and mobility. There's a lot of research that goes into this. My favorite is in 2014, they were able to show that we had joint pain frequency which decreased about 76%, I'm sorry, 2018, this— Klobowski and de Klerk. Both of these I think were really interesting. Estrogen reduced joint pain in those patients. We have studies that show that testosterone improves joint pain in hypoandrogenic men. And then more recently, we've had a lot of interest in, in, in these hormones and their effects on joints. Vonda and her group did their study in 2024. We've seen a lot of review articles. It looks like interest is growing. And although we still don't have great science on how these sex hormones work specifically in the joint, I'm excited to see what's coming down the pipe. But what do we think about the joint itself? So in our practice, we do regenerative therapy. So how does a regenerative therapy, how does using PRP, does PRP or stem cell actually impact the way that the joint works? And how does— and how can hormone optimization help us? Well, it turns out, without going too crazy on this, both hormones and regenerative therapies sort of inhibit the same parts of the inflammatory cascade. So it affects that IL-6 tumor necrosis factor pathway, reduces all of these inflammatory markers, and both of these working together are almost synergetic. Synergistic. And then we reduce the amount of damaging cells that get into the joint, both by using metabolic optimization and PRP. So they're working on the same systems. It's really interesting. And then we also— cartilage, if we're, if we're doing hormone therapy and we're supporting cartilage health, and then we're coming in with a regenerative therapy, and then we're curing inflammation and helping the joint heal, it makes sense that it all works together. And that's what we find. How we doing? Everybody good? All right, 9 minutes, 9 minutes, then we all get to get— stand up and go pee. All right, cool. Well, hanging in there. I think the obvious question is, how do our patients do? And so we've been doing this now since '23, and our results are pretty remarkable. The typical, the typical kind of duration of effect for PRP is between— depending on the study that you look, it's between 8 and 18 months. We have PRP patients that are out 30 months now. Yeah, it's because I truly do believe that it's because of metabolic optimization. We're looking at this more closely in the office. This is La Merle. La Merle came to us in '23. She's really cool because she's one of our first true Pinnacle Method patients. She came to us just sick. She was overweight. This lady is like a bowling phenom. She loves bowling. So she came to us and she had a 3-year history of progressively worsening knee pain. Brain fog, weight gain, low motivation. Sound familiar? Yeah, yeah. So when we looked at her in June 2023, you can see her sed rate was elevated, her CRP was elevated. This lady doesn't have an infection or anything. She's chronically inflamed. Estradiol is in the, is in the toilet. Vitamin D real bad. And vitamin D, incidentally, for musculoskeletal is extremely critical. We want to optimize vitamin D in all these patients. I know everybody. I see everybody nodding. Absolutely. In an orthopedic room, they'd be like, "What? It says 40. Why you want it to be 100?" No, vitamin D is important, right? Yeah. Her X-rays show some moderate osteoarthritis. These are the types of X-rays that get me excited about a regenerative patient. We can see a fair amount of damage to the patellofemoral— this is the kneecap, right? The patella, patellofemoral joint. Joint spaces are well maintained. And so we did hormone optimization, and she had a pretty dramatic improvement after we just started cream. And we incorporated an anti-inflammatory diet. Anti-inflammatory diet is magic. We see people reduce their symptoms and joint pain by 30 to 50% within about 3 weeks, right? Yeah, preach. Just eat vegetables. It's pretty amazing. And protein, protein first though. Exactly. I see you there, JJ Virgin. Then we did some right knee regenerative therapy. So we did bone marrow aspirate and PRP. I do these in combination in a sequence. And her pain improved by about 90% after 2 months. And it wasn't just her knee, right? It was all of her joints. But her knee was really special to her, and she has the same amount of relief about 37 months later. That's a really long outcome. For regenerative therapies, right? Really good stuff. This is her latest labs. Sed rate's normal, CRP's normal, estradiol's good, vitamin D's good, and she's trucking right along. Her BMI— I know we don't love BMIs, but it's 28 now. She's feeling really good, brought her husband to us. We took his hemoglobin A1c from 11 to 5.7 in 6 months while we treated his shoulder pain. Isn't that cool? Makes me feel good. I didn't have to cut that guy at all. It's the best part. Our next patient, Ernest. So this guy comes in, he's a former pilot. He's retired. When he retired, he kind of plumped out a little bit and lost his motivation to work out. So when he came to us, he was really— that's not even in the right— Okay. Was it before that? There we go, okay. He had weight gain, he had fatigue, thank you very much, keep me on track. Trying to get to the bathroom, people. Exercise intolerance, you can see his BMI right there, total testosterone below 300, that is an independent risk factor for progression of arthritis every time in my book, I think that should be treated, right? We can see his estradiol, he's aromatizing just a bit. So maybe his bone's a little bit healthier, but it's also not that great. Vitamin D is low, A1C is 6. Nobody had ever told him he's a diabetic. How many of us are diagnosing diabetes every day? And they're like, people that look at me like, what do you mean 6.5? That ain't diabetes. Then I call a primary care doctor and it's like, well, it's not that bad. Yeah, it's really bad. We gotta do something about this man. Absolutely. So with him, we did an integrative orthopedic approach. We started that in '23. Kind of similar things. We did right knee regenerative therapies. His left knee was pretty far gone, and he'd had enough pain with that that he was like, "I just want you to replace it." And he didn't want to invest in left knee regenerative therapy. And I think sometimes surgery is a good option. We can change people's lives with surgery, but only if we do it with optimization in mind, right? Exactly. So not to beat the x-rays to death, but here we go. The right knee, we can see he's still got some space. Left knee is a little bit more advanced. I think now I would encourage him, with my experience in this now, I would encourage him to try regenerative therapies here before he got a knee replacement. But back then I was doing pretty nice knee replacements. So look how good this looks. Right? Sexy. Yeah. He's not just a nail though. So we did regenerative therapy over here. Look at this. This right here, his joint space is actually wider. Yeah, and it's not just from the injection, right? We helped him lose weight. We helped him optimize his metabolism. So that's really important. He lost about 30 pounds in 3 months. That's pretty rapid weight loss. We watch body composition. But he was really motivated. He's feeling great. He had much improved energy and stamina. And it was really important for us to get him here to this place before we did his surgery, right? And he just flew through his surgery. He still has some pain in his replaced knee as of 10/25, and he's very happy with the one we did regenerative therapy on at the same time, right? So he's like, "Man, maybe we should have done this, tried it on the left knee first." I like to try— let's try everything before we cut somebody, right? And then you can see his latest indices. Really nice and healthy. So in conclusion, guys, traditional treatments for joint pain are not addressing the underlying issues that we all recognize are important, right? Hormone optimization, in my opinion, is totally essential for joint integrity, for pain modulation, and for control of the inflammatory process. And we can combine these approaches with regenerative therapies or even surgery to enhance healing, to improve our outcomes, to help our patients live better, longer lives, right? And together, guys, we can all make a difference. So thank you very much. Appreciate it. If anybody wants to stalk me on Instagram, you can join my like 200 followers. You can scan that. This actually goes to my contact information if anybody wants anybody wants, like, just reach out, email, phone, happy to talk. Thank you very much.