Nutrition for the Musculoskeletal Practice

Presented by: Bruce Bond DC, DACBN

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Three Types of Cartilage

1. Hyaline cartilage

2. Elastic cartilage

3. Fibrocartilage

3Cramer, Gregory D. and Susan A. Darby. Basic Clinical Anatomy of the Spine, Spinal Cord, and ANS. St. Louis: Mosby, 1995:402.

Hyaline CartilageHyaline cartilage is found in most articular cartilages of joints throughout the body.1

Found lining articular surface of:• Nasal septum2

• Tracheal rings2

• Larynx2

• Costal cartilages2

• Covering articular surfaces of bones in synovial joints.1

• Articular cartilage

41. Cramer, Gregory D. and Susan A. Darby. Basic Clinical Anatomy of the Spine, Spinal Cord, and ANS. St. Louis: Mosby, 1995:394.2. Sunny Downstate Medical Center. 11 Dec. 2012. <http://ect.downstate.edu/courseware/histomanual/cartilage.html>

Articular Cartilage Structure

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Articular CartilageArticular Cartilage

ChondrocytesChondrocytes

GlycosaminoglycansGlycosaminoglycans CollagenCollagen

WaterWater

Articular CartilageComposed of basically two elements:

1. Cellular component – Chondrocytes which produce and maintain the intercellular matrix

2. Intercellular matrix– Water (~60% to 80% of matrix)– Protein polysaccharides called glycosaminoglycans (GAG) molecules

(~5% to 10% of matrix)– Examples of GAG molecules are keratin sulfate, chondroitin sulfate and

hyaluronic acid– Groups of GAG molecules are called proteoglycan aggregates – Collagen (~10% to 30% of matrix)

6Mcance, Kathryn, et al. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Missouri: Mosby Elsevier, 2010: 1551-1553.

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Chondrocyte Proteoglycan aggregate

Collagen fibril

Hyaluronic acid

Subchondral bone

Joint space

Articular Cartilage

Keratin sulfateChondroitin sulfate

Glycosaminoglycans

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Name Distribution

Hyaluronic acidE.g., synovial fluid, articular cartilage, skin, vitreous humor, ECM of loose connective tissue1, intervertebral disc3

Chondroitin sulfate E.g., cartilage, intervertebral disc4, bone, heart valves1, skin, and cornea4

Heparan sulfate E.g., basement membranes1, lung, liver, and aorta4

Dermatan sulfate E.g., skin, blood vessels, heart valves tendon, and lungs1

Keratin sulfate E.g., cornea, bone, cartilage aggregated with chondroitin sulfates1, and intervertebral disc4

1. The Medical Biochemistry Page. Michael W. King, PhD. 30 Oct. 2012. <http://themedicalbiochemistrypage.org/glycans.php>.2. Urban, Jill. and Sally Roberts. “Degeneration of the Intervertebral disc.” Arthritis Research Therapy 5(2003): 120-130.3. Inkinen, R.I, et al. “Hyaluronan distribution in the human and canine intervertebral disc and cartilage endplate.” The Histochemical Journal 31(1999): 579-587.4. Cramer, Gregory D. and Susan A. Darby. Basic Clinical Anatomy of the Spine, Spinal Cord, and ANS. St. Louis: Mosby, 1995:411.

• Biochemical and cellular changes in cartilage result in depletion of the GAG molecules and a subsequent drop in water content. The cartilage becomes thinner and is less able to provide the cushioning necessary during loading.

• Think of the analogy of a kitchen sponge; as it soaks up water it becomes soft and resilient. When it dries out, its physical characteristics change completely as it becomes less compliant.

• By supporting healthy GAG synthesis, water is drawn back into the cartilage matrix.

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Articular Cartilage: Blood SupplyArticular cartilage has no intrinsic blood supply.1

Chondrocytes must use diffusion to obtain nutrients needed for structure and function. Sources include:

• Blood vessels within the synovial membrane• Synovial fluid• Blood vessels in the adjacent subchondral bone2,3

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1. Mcance, Kathryn, et al. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Missouri: Mosby Elsevier, 2010: 15532. Pelletier, J.P ., Jovanovic, Fernandes, J.C., Manning, M.G., and Martel-Pelletier, J. 2000. “Selective inhibition of inducible nitric oxide synthase reduces

progression of experimental osteoarthritis in vivo: possible link with the reduction in chondrocyte apoptosis and caspase 3 level.” Arthritis & Rheumatism. 43(6):1290-9.

3. Mcance, Kathryn, et al. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Missouri: Mosby Elsevier, 2010: 384.

Minerals and Articular Cartilage• Minerals are important constituents of the enzyme systems that

control GAG and collagen synthesis in the cartilage matrix. • E.g.,

– Manganese is a trace mineral which has a role in collagen synthesis and the synthesis of glycosaminoglycans.1

– Zinc is a component of the enzyme that controls the production of collagen in the cartilage matrix.2

– Copper dependent enzymes are also involved in the linking of collagen and elastin.3

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References for Previous Slide

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1. Bucci, Luke. Nutrition Applied to Injury and Rehabilitation and Sports Medicine. Florida: CRC Press, 1995: 141-142.

2. Marshall, William J. and Stephan K, Bangert. Clinical Biochemistry. China: ChurchHill, Livingstone Elsevier, 2008: 196.

3. Turnlund JR. Copper. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, eds. Modern Nutrition in Health and Disease. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2006: 286-299.

Intervertebral Disc (IVD)Each IVD is reinforced peripherally by two ligaments1

1. Anterior longitudinal ligament2. Posterior longitudinal ligament

Consists of three main parts1

1. Outer anulus fibrosus2. Inner gelatinous nucleus pulposus3. Cartilaginous end plates (i.e., vertebral end-plate)

• Consists of hyaline and fibrocartilage.2

The anulus fibrosus, nucleus pulposus, and vertebral endplates all consist of water, cells (i.e., chondrocytes, proteoglycans), and collagen.1

131. Cramer, Gregory D. and Susan A. Darby. Basic Clinical Anatomy of the Spine, Spinal Cord, and ANS. St. Louis: Mosby, 1995: 406-417.2. Cramer, Gregory D. and Susan A. Darby. Basic Clinical Anatomy of the Spine, Spinal Cord, and ANS. St. Louis: Mosby, 1995: 36.

Fibrocartilage

Vertebral End-Plate

Composed of:• Chondrocytes• Collagen• Glycosaminoglycans

• Proteoglycan aggregates

14Moore, Robert J. “The Vertebral Endplate: Disc Degeneration, Disc Regeneration.” European Spine Journal 12(Suppl 3) 2006: 333-337.

Vertebral body

Nucleus pulposus

Annulus fibrosus

End plate

* Not all structures shown

Intervertebral Disc (IVD)Blood supply

• In adult discs, blood vessels are normally restricted to the outmost layers of the anulus.1

• The nucleus pulposus and inner anulus of the disc are supplied by capillaries that arise in the vertebral bodies, penetrate the subchondral bone, and terminate at the vertebral end-plate.1

• The vertebral endplate is porous and this porosity allows fluid and other metabolites to enter and leave the anulus fibrosus and nucleus pulposus by osmotic action.2

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1. Grunhagen T., Wilde G., Soukane D.M., Shirazi-Adl S.A. and Urban J.P.G. “Nutrient supply and intervertebral disc metabolism”. The Journal of Bone and Joint Surgery 2006; 88: 30-3.

2. Humzah, M.D. & Soames, R.W. “Human Intervertebral Disc Structure and Function”. Anatomical Record, 220 (1988): 337-356

Tendon and LigamentsTendon and ligament major constituents1,2

• Water1

• Collagen1

• Fibroblasts: Responsible for the production and maintenance of tendon collagen and non-collagenous constituents1

• Fibrocartilage: Occurs in the tendon … both where the tendon inserts into bone … and where it wraps under the bone. 1

• Proteoglycans: Make up less than 1% of the dry weight of tensile tendons.1

161. Vogel, KG. “Tendon Structure and Response to Changing Mechanical Load.” Journal of Musculoskeletal & Neuronal Interactions. 2003; 3(4):323-3252. Berger, Richard A. and Arnold-Peter C. Weiss. Hand Surgery. Philadelphia: Lipponcott Williams and Wilkins, 2004: 25

Meniscus• Menisci

• Fibrocartilage which consists of:• Chondrocytes• Proteoglycans• Collagen• Water1,2

• Blood supply• Limited to the outer one-third of each menisci3

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1. Mow, Van C. and Rik Huiskes. Basic Orthopeaedic Biomechanics and Mechano-Biology. Philadelphia: Lippincott Williams & Wilkins, 2005: 196-198.2. Beaufils, Philippe Beaufils. The Meniscus. New York: Spinger, 2010: 20-21.3. Beaufils, Philippe Beaufils. The Meniscus. New York: Spinger, 2010: 15.

Glucosamine Synergy®

Glucosamine sulfate (500mg)

Boswellia serrataextract (60mg)

Bone PMG™ extractBone mealBovine heart

PMG ™ extractManganeseCarbamideTillandsia usneoides

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Calcium lactateNutritional yeastLiverDefatted wheat germMagnesiumOat flourPea vine juiceRNAAdrenal Cytosol™ extractBeet root powderMushroom powderFlaxseed oil extractCholecalciferol+ + +

1 capsule 3x/day

Ligaplex® I

Manganese B12™

Cataplex® EOstrophin PMG®

Cataplex® A-C-P

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1 capsule 3x/day

Contains a combination of key ingredients from:

Boswellia Complex

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Boswellia gum oleoresin 7:1 extract 277 mgfrom Boswellia serrata gum oleoresin 1.9 gcontaining boswellic acids 180 mg

Celery Seed fruit 6:1 extract 166.7 mg from Apium graveolens fruit 1.0 g

Ginger rhizome 5:1 extract 60 mgfrom Zingiber officinale rhizome 300 mg

Turmeric rhizome 25:1 extract 80 mgfrom Curcuma longa rhizome 2.0 gcontaining curcuminoids 70.4 mg

1 tablet/3-4 times per day

Thank You for Attending

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