Facilitated

11| Diagnosing The Biology: Why Cortisone Injections Aren't Fixing Chronic Pain

• The Facility Denver • Episode 11

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A holistic approach to chronic pain requires looking beyond symptoms to identify underlying causes and triggers in the full biological picture. Our patient with chronic tendon pain had multiple contributing factors that cortisone injections alone couldn't address.

• Iron overload discovered as a major driver of chronic joint pain that conventional treatment missed
• Thyroid function optimization through dietary approaches rather than medication
• Importance of iodine sources like seaweed when using non-iodized salt
• Connection between gut microbiome health and thyroid hormone activation
• How mindful eating practices dramatically improved bloating and nutrient absorption
• Understanding how high iron levels create harmful free radicals that deplete antioxidants
• Comprehensive testing revealed four independent reasons preventing tendon healing
• Collaborative care approach combining lifestyle, nutrition, and targeted therapies [thanks, Dr. Arianna Wendlandt!]

If you're feeling curious or ready to take a deeper look under the hood, you can explore the lab options anytime at thefacilitydenver.com. And remember lab data is just the beginning. If you need help interpreting your results, we're here for that too.


Want to take the next step with functional medicine? Learn more about our new patient process and lab testing at www.thefacilitydenver.com

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Stay curious, stay proactive, and we’ll catch you next time!

Speaker 1:

Welcome to Facilitated, where we bring you real stories, strategies and science from the world of functional medicine. I'm Dr Mitchell Rasmussen, a functional medicine practitioner.

Speaker 2:

And I'm Kate Daugherty, a certified nutritionist. We are the owners of the Facility, a functional medicine clinic here in Denver, Colorado.

Speaker 1:

We help people improve their biology and get out of their own way. In my view, our work is about getting to know the person with the condition much more than it's about understanding which condition the person has. As I always say, diagnose the biology, not the disease.

Speaker 2:

On this podcast we break down complex health topics, share real patient cases anonymized, of course and explore cutting-edge wellness strategies so you can make informed decisions about your health. Quick heads up before we dive in this podcast is for education and general information only. We're here to share insights, not to diagnose or treat. So if you're dealing with a health issue, chat with a qualified healthcare provider before making any changes. All right, let's get into it.

Speaker 1:

Good afternoon, happy Thursday, best day of the week.

Speaker 2:

Yay.

Speaker 1:

Right. Something I wanted to talk about today was actually share a little bit about a patient, a recent patient case, and then impress upon you, the listener, the importance of what you I guess the word holistic approach, kind of, has become a little bit muddied to mean just natural woo-woo, and what I mean is taking an approach of emotional, physical, biological stress, all of those things, and working with other providers to find what's actually causing symptoms. And you know where I'm going with this patient. So we had a gal mid-30s who came in with a history of blood sugar issues, a little bit of weight gain, as well as energy and chronic tendon pain, and she I asked what she has previously done and she had been to an orthopedist who, without any sort of history or labs, injected her a couple times with cortisone. And throughout the history it became clear to me that there was something missed in that workout, or probably a lot of things, because when I hear a chronic tendinopathy or arthritic type of thing, family history is so relevant. Do you have a family history of rheumatism or autoimmunity, in which case, yes, she did. And then diet Are you eating enough protein? Are you balancing your blood sugars to keep your stress normalized and what's going on as far as your thyroid? She was told that her thyroid was normal.

Speaker 1:

All this to say, we ran a bunch of labs and what we found was you're right, your thyroid is air quotes normal. There's no Hashimoto's. We ran an autoimmune testing. We were able to rule out rheumatoid arthritis. We definitely have some stress hormone issues. Cortisol was all over the place.

Speaker 1:

But she had an interesting finding, which was her iron was through the roof. Iron was through the roof, and one thing we know about iron is that it can lead to arthritic type conditions and chronic joint pain. And I became at once, I guess, happy that we found it, but also frustrated that this person was just essentially not worked up or guided and just injected with a powerful steroid over and over again, with no attention paid to the other, what we call the antecedents or the triggers in functional medicine, the whole picture. What is her treatment? Well, kate, for thyroid, when we see a picture of a normal brain signaling and no autoimmune patterns, no thyroid peroxidase, no thyroglobulin antibodies and then all levels within normal, but thyroid hormone T4, low normal and active thyroid hormone T3, low normal as well. Do you remember what our first intervention with her was for that?

Speaker 2:

Yeah. So two parts to this. It's do we have the raw materials to make enough thyroid hormone and do we have the cofactors positive cofactors as well as negative inputs under control so that the conversion from T4 to T3, which is the active hormone, happens efficiently? So when we think enough materials to make thyroid hormone, thyroid hormone is say it for me.

Speaker 1:

Oh, tyrosine with four iodines.

Speaker 2:

Oh, I thought you were going to say the actual name.

Speaker 1:

Oh, like tetraiodothyronine. Thank you, thyroxine.

Speaker 2:

Thyroxine, thyroid hormone. For iodines. Iodine is an interesting one. We really don't get a lot of iodine naturally in our American diet. A lot of people have switched over to a natural salt, meaning a non-iodized salt. That was the primary source where we were getting it in our table salt, but now, with all these patients using natural salt sea salt, lake salt, it's we're missing iodine. And another primary source of iodine is shellfish. This patient happened to have a shellfish allergy, so she wasn't consuming any shellfish either, so that's where we think Say that three times fast, shellfish.

Speaker 1:

I'm watching you try to say it, shellfish. So she just wasn't getting the raw materials. When we think about thyroid function, if your levels are all normal and I understand from a medical perspective that the air quote we can't do anything for you and that's because the prime intervention is synthetic thyroid hormone. But if your levels fall within a tight range or a wide range, which is like four and a half to twelve or so or ten, typically no treatment is offered because the treatment is a medication that only can be given in these very black and white situations. With some exceptions if someone has a somewhat elevated TSH and they are trying to conceive, they might be put on a low level thyroid hormone. But a general population will essentially be told we'll recheck in six months and we'll keep moving. What I love about the way that you approach these thyroid issues is, I think functional medicine gets a bad rap where it's just take a bunch of supplements.

Speaker 1:

For this person it was about having her diet give her the raw materials to make the adequate hormones. You could give her an iodine supplement, but we could just as easy have her get a whole food form in, like we said with her, the seaweed Next let's talk about. So that's T4. That's how to give her the raw materials to make thyroid hormone. And there's other things like adequate protein in the diet, enough zinc, enough vitamin d, vitamin a. There's so many different things that help the body create t4. But t4 is really metabolically inactive.

Speaker 1:

The more active form form is T3, which essentially T4 becomes deiodinated where an enzyme rips off an iodine molecule and it turns it into T3, which is tyrosine with three iodines on it. That conversion is severely impacted when cortisol is dysregulated, so when your stress is not managed properly. We know that a massive chunk of this deiodination actually happens within the gut microbiome. So this person struggling with chronic bloating was actually avoiding certain prebiotic foods that could lend themselves to a healthy gut microbiome that could help her deiodinate better. So this is how now her gut issue was essentially leading to poor output and conversion of thyroid hormones, which was then contributing to some of this inability for her tendons and her blood vessels to get enough oxygenation. So getting her to work on her microbiome by getting her to improve her bloating happened in the first visit. Before we even got labs back, she came back and was blown away that just chewing her food, slowing down her meals and avoiding liquids expanded her diet completely before we even got any data back.

Speaker 2:

And actually a big one for her was she wasn't taking a lunch break. She was eating her lunch while working on her computer, and so that was a big directive we gave her was can you actually give yourself a lunch break? Put your computer away and focus on only eating, which, in turn, improved how focused she was on chewing how mindful she was of the whole experience.

Speaker 1:

So now her bloating goes away, when we know when you're less bloated you're getting better chopping apart of the foods you're eating, so that now you're able to actually eat the foods that will deliver not just nutrients but will deliver substrate to the microbiome, in order for the microbiome to be healthy and diverse so that you can deiodinate better. We talked about stress. The gut microbiome, the liver, is also a massive part of how well we activate thyroid hormone. Activate thyroid hormone when you have a loss of b vitamins or glutathione on top of various other nutrients like amino acids and antioxidants.

Speaker 1:

We know that the liver will not be processing things as well and it won't show up with elevated liver enzymes. It will show up with a high homocysteine, potentially, or a low serum B12, things like that. That was also a factor for this person was improving her methylation, improving her liver function, so that she could then have that other huge chunk of diiodination. I think so often in our field the idea of we just need to take a bunch of supplements becomes kind of the norm, because I would say that's easy for practitioners to just load up on supplements. But for this person it was like you said the timing and how she ate, the environment around eating, creating that microbiome working on her parasympathetic tone and then including the food-based nutrients that could give her the raw materials. What I love about how you approach these is we know selenium is so important for thyroid function. Instead of giving you a supplement, we just give you the top source of selenium in the diet.

Speaker 2:

Which is Brazil nuts.

Speaker 1:

Which big fans. We got Brazil nuts, we got seaweed, and then for her, because of the shellfish issue, kate couldn't give her usual, which is oysters. Oysters are by far the best source of zinc with a balance of copper in the diet, so typically that's what we would do, but for her that ended up becoming pumpkin seeds and a zinc supplement.

Speaker 2:

Yeah, there are other sources of zinc. Like you said, pumpkin seeds, other nuts and seeds will have some zinc in them. But for her specifically, she was already consuming a decent amount of pumpkin seeds before we got her lab results and her lab results still showed a need for zinc.

Speaker 1:

Yeah. So then we started to find again. This was a history that led us to thinking okay, you've always had normal thyroid labs, let's dive a little deeper. Let's look at the nuance. You're having this GI issue that can lend itself to all of these systemic issues. So now we've started to cover up these massive biochemical sinks, if you will, that are not allowing her distal tendons to get the nutrients they need to heal.

Speaker 1:

And then we found a massive smoking gun, which on one hand, I was happy we found, but on another hand, I was actually quite frustrated that this orthopedist was so willing to just keep injecting her without doing any sort of lab work. She had an iron level through the roof, not just her ferritin but also how saturated her cells were with iron. And we have her give blood, we do all these things and as well as some PMF, and we had her see Dr Ari to do some dry needling and a few things like hands-on therapies, and she's already light years ahead of where she was with these cortisone injections. And to me that's kind of why we do what we do, why we slow down, take a big history, do intensive diet analysis, stress analysis and take comprehensive labs, because we found four independent reasons for this person to not have their tendons heal, and you can find this in the literature. We know and the mechanism is not really clear to me how high iron. I'm sure it's because it drives the Fenton reaction, which catalyzes the creation of the most damaging free radical in biology, the hydroxyl radical, which we know then reinforces how the liver gets stressed because it depletes glutathione. Because our bodies actually do a magic trick when there's high iron, the body will use glutathione to essentially donate a hydrogen. A hydroxyl radical is an O and an H, an oxygen and a hydrogen with a negative charge and an unpaired electron, with a negative charge and an unpaired electron. And essentially what these electron donors do antioxidants is glutathione will donate a hydrogen, an unpaired electron, so it essentially turns this highly oxidative molecule, the hydroxyl radical. That's happening in her body because of her iron, which catalyzes the creation. It will turn it into water. It's like magic. Now we're able to replete her antioxidants, give her enough donation of hydrogen to be able to stabilize these free radicals and immediately this person's nerve will get enough oxygen and will have less of this oxidative burden. So now their body is set into a place where it can truly heal. So again like going backward.

Speaker 1:

When this woman came in, my thoughts were poor parasympathetic tone, high sympathetic tone. We know that vasoconstriction of blood vessels from high sympathetic tone not only raises blood pressure but it also impairs the ability of neurons to receive one of their most important things, which is oxygen. I was thinking autoimmunity or thyroid disease. We did quite a few autoimmune markers and she had no rheumatoid arthritis. But potentially there is definitely some autoimmune involvement with a positive ANA that we're recommending she follows up with a rheumatologist on. But then we also found this other massive stopper of oxygen delivery, which is too much iron in the blood. So by fixing these basic mechanistic things now this person's body is completely primed to be able to get over this problem without any injections and with much more quality of life.

Speaker 1:

And the fun thing that we do is there's really mostly only side benefits. Besides the occasional person that gets loose stools from too much magnesium or say they had their gallbladder out and they're not tolerating fish oil or things like that, almost always, by us helping align the person's biology with its requirements, all of these side things go away. Your main symptoms get better, of course, but then now if she's carrying oxygen more appropriately. She doesn't get dizzy when she stands up fast. She's able to work out longer without shortness of breath. She no longer thinks she has heart disease because she has to pant going upstairs. All of these little things that just kind of creeped into her normal life that were all being driven by basic, fundamental flaws in the way her system was moving things around, activating things and clearing things. Boom, that was a win, wow, and I want to thank Kate for allowing us to do this today without any notes.

Speaker 2:

No notes. We went into this one blind.

Speaker 1:

I was along for the ride with you and I think our goal is to share more technical information about what we do, because I think we do some really sweet things. But I think it's been fun kind of talking more philosophy, as we've started this podcast thing and we'll kind of see it adapt as we go.

Speaker 2:

If you're feeling curious or ready to take a deeper look under the hood, you can explore the lab options anytime at thefacilitydenvercom. And remember lab data is just the beginning. If you need help interpreting your results, we're here for that too. Thanks for tuning in and for being the kind of person who takes health seriously before it becomes a crisis. Now go, facilitate your own health and we'll see you next time.