"To Health"

1. Why is the ankle I sprained 4 weeks ago still swollen and painful?

Ligaments are simply like ropes that hold bones together. Your knee bends and straightens in a single plane; it does not bend sideways. Ligaments are the structures that allow this type of motion. Some motions of joints are relatively simple like an elbow or finger joint. Others are much more complex like a shoulder or hip. Ligaments must have the right amount of tightness through the complete motion of the joint.

Some ligament sprains are quite mild where only a few of the fibers are stretched or torn. Some are very severe where the entire ligament is torn in half. Most ligament injuries heal simply by letting the fibers come together as you would let a skin edges of a laceration come together. However, just as some lacerations require sutures, some ligament tears require surgery. In the most complex ligament injuries even surgery to sew the ligament together does not provide a stable, strong result. In these cases a new ligament is made frequently from other structures in the body. This is how Kerry Wood's severe elbow ligament injury was treated.

As a ligament heals it is important to maintain the strength of the extremity. Exercises should be begun as soon as possible to keep the extremity strong. When it comes to rehabilitating a knee or ankle, it is also necessary to maintain or develop a sense of balance so that, by reflex, your body can tighten the appropriate muscles to prevent injury. Medical professionals call this "proprioception."

If you are still having pain and swelling 4 weeks after twisting an ankle, this tells me that you had a fairly severe sprain. There are certain exercises your physician or physical therapist can give you that will speed your recovery.

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2. Without any apparent injury my shoulder has become stiff and painful. What can I do?

You probably are describing a condition called "Frozen Shoulder" or "Adhesive Capsulitis." This is an enigmatic problem that causes pain and reduced range of motion. It usually begins in middle aged people without known cause. Sometimes however, it is associated with a specific illness or event. For example, someone who has had breast or heart surgery will suddenly realize that his or her shoulder does not move well.

The ligaments that hold the arm bone to the shoulder socket become thickened and do not stretch as they should. This means that you can move your arm bone just so far before there is an impasse. X-rays and blood test are all normal in this condition.

Early in the course of this disease I recommend rest and simple exercises such as swinging your arm back and forth like a pendulum, and using your fingers to help you walk up a wall. Physical Therapy and cortisone injections are often very helpful. When all else fails I will sometimes manipulate and stretch the joint while the patient is under anesthesia.

While your prognosis is excellent, it usually takes several months to recover completely. A minority of patients will lose a little motion which generally does not interfere with normal daily activities.

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3. Whenever I lift or grasp an object I have severe elbow pain. What can I do?

The most common cause of elbow pain is lateral epicondylitis, more commonly called tennis elbow. In most people this condition is not caused by playing tennis but rather by an accumulation of small traumatic events, such as repetitive manual labor activities.

The muscles that extend your wrist and fingers originate from the bone on the outside part of your elbow. The muscles extend from this area and connect to tendons which then attach to the bones in your hand and wrist. When you want to grip an object, the muscle contracts. In effect, it stabilizes your wrist and allows you to hold the object.

There will be tenderness specifically when you press the outside bone in the elbow called the lateral epicondyle. If when you lift your wrist against resistance and get pain in your elbow, you have confirmed this diagnosis.

There is no treatment for tennis elbow that produces immediate results. Rest and avoidance of activities that produce pain are important. I also recommend ice massage. Freeze water in a small paper cup then massage the outside part of the elbow in small circular motion until it feels numb.

Stretching exercises of the affected muscle are also very important. Straighten your elbow, then with the noninvolved hand slowly bend the involved wrist and hold it in this flexed position for about a minute. Repeat this a couple of times. It is helpful to use ice massage after this.

Your physician may offer you anti-inflamatory medication and if your problem persists an injection of a corticosteroid. Physical therapy can also help to reduce pain, and restore flexibility and strength. You also may get some pain relief by wearing a strap just below the elbow.

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4. I have degenerative arthritis of my knees and my doctor has recommended a total joint replacement. How do I know that it is time?

The decision to proceed with a total joint replacement is rarely easy. A patient with osteoarthritis usually experiences a gradual increase in pain and functional disability. He or she will have fewer and fewer good days and pain will frequently affect sleep. Normal daily activities such a shopping and climbing stairs become exceedingly difficult. Medication, injections and other treatments lose their effectiveness and it is easy to become depressed.

The physician will note objective changes. The affected joint will be persistently swollen. He will be able to feel the noise produced by the roughened joint surfaces. X-rays will show loss of cartilage thickness, spurs and bone cysts. I frequently see x-rays where there is a tremendous amount of damage but the patient has little pain and can even do physical labor. Then again, I see x-rays that show little arthritic change, but the patient is markedly disabled. For this reason I always tell my patients that I treat patients not x-rays.

If all other treatment options are exhausted, the conditions are present to consider surgery. One must also weigh the contraindications to surgery. Has the patient had a previous infection in the affected joint? Does the patient have a heart condition that makes surgery too risky? Can the patient tolerate the anesthesia that is required?

There certainly are risks with any operation. Both the patient and physician must understand these so as to take precautions to prevent problems during and after the surgery. There will be pain associated with surgery, but this will be controlled with medication. Furthermore there will be a tremendous amount of effort the patient must devote to therapy and rehabilitation.

While the physician can weigh the conditions, indications and contraindications and recommend surgery, the patient must ultimately make the decision based on pain and disability. Because joint replacement surgery is so successful it is rare for a patient to say he or she is sorry that it was done.

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5. I have had back pain for a number of years and now the pain is affecting my legs. My doctor says that I may need surgery because the vertebrae have slipped out of position. I am a 68-year-old female. What other options are available?

A condition called degenerative spondylolisthesis is very common in your age group. There is a forward displacement of the forth lumbar vertebrae (L4) in relation to the fifth lumbar vertebrae (L5). As a result, the spinal canal becomes smaller and the nerves that travel through it become pinched. We call the narrowing of the canal “spinal stenosis.”

Women are more commonly affected than men. The prevalence of this condition increases with age. In contrast, men get ischemic spondylolisthesis that usually occurs at L5-S1. Symptoms of this condition generally improve with age.

The most common complaint is back pain. The pain frequently comes and goes. It often gets worse over the course of the day. As the disease progresses, pain radiates into the back and sides of the hips. Thereafter it may affect all of the legs. Leaning forward can sometimes relieve these symptoms because this tends to increase the size of the spinal canal. Additional complaints include cold feet, altered gait and episodes where one unexpectedly falls. In the extreme, bladder and bowel control is lost.

Conservative treatment includes the use of nonsteroidal anti-inflammatory medication, conditioning exercises, weight reduction, and braces. Back braces tend to stabilize the spine, just as a tube of toothpaste becomes stiffer if you grasp it tightly in the middle and squeeze (with the top on of course). Epidural injections of cortisone into the spine can be helpful.

Probably about 10% of patients with degenerative spondylolisthesis cannot be managed without surgery. The canal is too small and opening it by removing a bridge of bone can relieve the pressure. This is called a laminectomy.

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6. I developed severe swelling and redness in my foot without any injury that I recall. My doctor found that several bones were dislocated. How can this happen?

The sensation of pain is the most important protector of your body. Imagine stepping barefoot on a marble. Normally, you limp until the acute pain wears off. The pain you experience protects you. But if your body does not feel pain, you continue to walk and not protect your foot from further injury. Repeated relatively minor insults can result in destruction of bones and joints. This is called Neuropathic Arthropathy, one of the most interesting and unusual degenerative joint abnormalities.

There are many causes for the loss of sensation to an extremity. One of the most common is diabetes. Diabetics frequently experience numbness in their feet. About one per cent of all diabetics will develop this destructive joint disease called Neuropathic Arthropathy or Charcot Disease. Any disease that affects sensation to your feet can result in this condition.

In 1868 Jean Martin Charcot, a French physician, described this condition in patients with advanced syphilis. Syphilis, alcoholism and leprosy are other conditions that cause loss of sensation in the feet. At that time insulin had not been invented so diabetics did not live long enough to develop this disease.

It usually takes at least 10 years to develop neuropathic arthropathy. Most patients have adult-onset diabetes and therefore do not develop this condition until they are over 40.

In the initial presentation, the bones of the foot break and lose their secure attachments to adjoining bones. This could be what happened to your foot. Anyone who has diabetes or any other condition that affects the sensation of the foot should seek immediate medical attention if unexplained swelling, redness or warmth occurs.

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7. I read about a 17 year old high school student who died while playing basketball. What can cause sudden death in an apparently healthy person?

Most people feel that young competitive athletes are the healthiest members of our society, so even one unexpected death has a tremendous psychological impact. Statistics show that death during high school athletic participation occurs in 1 in 200,000 athletes per academic year.

The single most common cause of such a tragic event is hypertrophic cardiomyopathy. (HCM) In this condition the heart muscle thickens but the cavity that fills with blood stays normal size. A doctor listening to the heart will detect no abnormalities because the blood flows through the heart normally. Thus in a routine physical exam it is virtually impossible to detect this condition and identify those athletes who will be prone to sudden death.

Identification of the athlete with HCM is a major challenge. Frequently, there is a genetic abnormality. Thus a family history of death at an early age from a heart related cause should raise a red flag at the time of the preparticipation screening. An athlete who complains of dizziness when he exerts himself could also suggest HCM.

During intense exercise HCM can cause an abnormal heart rhythm where the heart loses its ability to pump blood to the brain and other parts of the body. Normally the heart allows blood to enter, and when it is full it contracts to push blood through the arteries to the rest of the body. When there is an arrhythmia the heart contracts erratically and loses its ability to function as a pump. Successful resuscitation is only possible if appropriate measures are undertaken immediately.

Because of the unacceptable risk of sudden cardiac death one thing is certain. An athlete who has HCM should not participate in sports with the possible exception of low intensity activities.

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8. I was diagnosed with breast cancer and my doctor said the cancer has spread to my thighbone. He wants me to see an orthopaedic surgeon about surgery to prevent this bone from breaking. Why?

The spread of cancer to bones of the body is called “metastatic bone disease.” Multiple bones of the body can be affected, such as the skull, ribs, spine, pelvis and long bones.

Breast cancer can invade and destroy parts of a bone compromising its strength. As a result, a trivial injury or stress can cause the bone to break. An orthopaedic surgeon can frequently use a rod or pin to stabilize your thighbone before it actually breaks. Of course, a surgeon does not want to do surgery unnecessarily, so he uses a scoring system to try to predict an impending fracture. He takes into consideration the bone that is affected, the size of the lesion, the appearance of the lesion, and the amount of pain that you have.

The most common symptom of metastatic bone disease is pain. It is usually described as a deep, aching sensation. It tends to be worse at night and can be decreased by activity. Symptoms usually increase as the lesion gets larger.

Not all metastatic tumors require surgery. Chemotherapy and hormonal therapies are the mainstays of treatment. Radiation therapy is commonly used for painful lesions. Braces are sometimes used to prevent bone fractures.

I cannot stress the importance of breast cancer screening. Early detection of cancer will decrease complications such as metastatic bone disease.

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9. I suddenly developed pain in my hip without falling or even missing a step. X-rays subsequently revealed a fracture that required surgery. Why did this occur?

You developed a fracture, that is a break in the bone, from repetitive stress to the upper part of your thighbone near the hip joint. This is called a stress fracture. Stress fractures are common in athletes and military recruits but also occur in about 1% of the general population.

Bone is a vital dynamic structure. It is constantly being produced and broken down. Imagine a sand castle on the beach. You keep adding sand to your structure but the waves never stop washing some away. As long as you can keep patching your castle it will survive. If the waves come more frequently and you cannot keep up, then the castle is at risk of breaking apart.

Bone is like this castle. During periods of exercise, bone formation lags behind bone resorbtion and the bone becomes weaker. Under repetitive loading conditions a microscopic crack may occur. If your body cannot repair this crack fast enough it will get bigger and eventually form a stress fracture.

The classic presentation is a patient who experiences the insidious onset of pain after an increase in his or her intensity or duration of exercise. The weight bearing bones of the lower extremity are most commonly affected. X-rays are typically normal for the first 2 to 3 weeks after the onset of symptoms. The break in the bone is simply too small to see. Other tests such as bone scan, CAT scan or MRI may be helpful.

While most stress fractures can be treated with rest and restriction of the offending activity, some require surgery. You apparently had a fracture in the neck of the femur. Normal weight-bearing and muscle forces in this area can commonly cause the fracture to displace. To prevent this from happening, pins are used to hold the fracture in place and allow it to heal.

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10. I have gotten in the habit of stretching before and after I work out but I don’t know why. Is stretching really important?

Over the past few decades stretching exercises have become very popular. Our main goals in stretching are to prevent injury, enhance performance, and decrease muscle pain that can occur after a vigorous exercise. It should be part of a total sports program because by itself stretching has little value. There are different methods of stretching and it is important to understand the benefits and risks in utilizing each of these methods.

“Static” stretching is the best and safest. This requires a slow controlled elongation of a relaxed muscle. You should feel a “pull,” but not pain, and you should hold this position for about 30 seconds.

“Ballistic” stretching involves rapid bouncing to stretch the muscle. This type of stress can result in excessive loading and can stretch the muscle beyond its elastic capacity, like stretching a rubber band until it breaks.

Proprioceptive neuromuscular facilitation (PNF) is a technique where you first contract a muscle, then relax and stretch it. Though you can increase range of motion quickly, you are more likely to experience considerable pain and even injure the muscle.

Ideally, stretching should be preceded by about 5 minutes of easy active exercise to warm the muscles. With an increase in temperature tissues become less resistant to stretch. Slow jogging, bicycling, and arm circling are good activities to achieve this.

If you have arthritis, the shape of the bones in a joint may change and it may be impossible to increase your range of motion. This is analogous to a door that opens only as far as the wall that stops it. Further pushing on it will only damage the wall. If there is bony obstruction to joint motion, attempts to move it farther will only cause pain and aggravate your arthritic symptoms.

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11. If I switch from smoking cigarettes to cigars will I decrease the risk of health problems?

Your risk of dying from cigars will be very similar to your risk of dying from cigarettes. So don’t switch – stop! Cigar smoke has 63 has constituents that are carcinogenic (cancer producing). The tobacco is fermented, while cigarette tobacco is heat-cured. Fermentation contributes to the flavor and aroma, but produces nitrosamines that are carcinogenic. Cigar tobacco is rich in nornicotine and nicotine – again also carcinogenic. The tar produced by cigars exerts greater tumor producing activity in mice than cigarettes. It is easy to see why there is an increased risk of mouth, esophageal, laryngeal and lung cancer.

The nicotine in a single cigar can vary from the amount generated by a single cigarette to a pack of cigarettes. The alkalinity of cigar smoke aerosal particles deters inhalation though usually the smoke is at least partially inhaled. In fact, because you have smoked cigarettes, you are more likely to inhale cigar smoke. Smoking cigars instead of cigarettes does not reduce the risk of becoming addicted to nicotine.

In recent years cigars have been promoted and glamorized. The cigar industry has intensified its public relations efforts through magazines, cigar banquets and other functions, product placement and feature stories. Advertising includes sexual imagery, athleticism, affluence and celebrity endorsement. It is clear to see why the rate of cigar smoking is rising. Furthermore, the industry is not required to mention health risks like it must with cigarettes.

Don’t be mislead or manipulated. Your body deserves clean air and a clean environment. Your life may depend on it.

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12. I will be having a total hip replacement in a few weeks. What sports activities can I participate in after I have recovered?

After your surgery you will do exercises to strengthen the muscles that support your joints. Strong leg muscles will help you to return to those activities of daily living such as walking, climbing stairs, getting up from a chair and getting into and out of a vehicle. Usually it takes about 3 months before your doctor will allow you to return to sports.

In addition to relieving pain, many people opt to have total joint replacement surgery to be able to return to sports. Some strenuous sports activities have the potential to damage artificial joints. All mechanical objects given enough time and stress will fail. The current metals, plastics, and ceramics are engineered and designed so well they usually do not break or even wear that much. What fails?

A joint replacement fails when it becomes loose or because the bone supporting the implant dissolves. These 2 reasons for failure are related. Wear of an artificial joint produces debris. The debris works its way to the interface between metal and bone causing the bone to dissolve and the implant subsequently loosens.

The greater the forces applied to an artificial joint the greater the potential to produce debris. Researchers have analyzed the forces generated across joints during various activities. For example, when you walk the force across your hip joint is 1.2 times your weight. When you run the force across your hip is 2.5 times your weight. When you sprint the force is almost 4 times your weight. This is also an argument to maintain a reasonable weight after your surgery.

Low impact sports are generally the rule. You should be able to participate in bicycling, swimming, bowling, golf, non-aggressive doubles tennis, walking, and other similar activities. Football, basketball, baseball and volleyball are not acceptable. You should ask your doctor specifically which sports are advisable for your particular situation.

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13. I have a golf ball sized lump on the point of my elbow. What is it? What can I do?

You have an inflammation in your olecranon bursa that we call olecranon bursitis. There are many lubricating sacs throughout your body called bursae. When two structures have to rub against each other there will be a bursa that provides the necessary lubrication.

Imagine a collapsed balloon with a couple of drops of oil in it. If you rub this between your fingers you will understand what a bursa does. Your skin has to slide over your elbow bone as you bend and straighten your elbow, hence, the olecranon bursa.

Any irritation of a bursa will cause it to fill with a watery fluid. Frequent resting of your elbow against a tabletop can cause olecranon bursitis, but usually we cannot definitely find the cause.

Your doctor will be able to make the diagnosis by feeling your elbow. He may stick a needle in it to remove the fluid and may inject cortisone to decrease the inflammation. Rarely the bursa will need to be excised surgically.

The bursa may also become inflamed because of infection. Usually redness, warmth, and pain are signs of a “septic” olecranon bursitis, which needs immediate attention with antibiotics and sometimes even surgery.

Another bursa that commonly becomes inflamed is in the front of your knee. Repetitive kneeling can cause this bursitis, which gives it its name – “Housemaids Knee.” Again, it is extremely important to rule out infection as a cause of this bursitis.

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14. Whenever I lift or grasp an object I have severe elbow pain. What can I do?

The most common cause of elbow pain is lateral epicondylitis, more commonly called tennis elbow. In most people this condition is not caused by playing tennis but rather by an accumulation of small traumatic events, such as repetitive manual labor activities.

The muscles that extend your wrist and fingers originate from the bone on the outside part of your elbow. The muscles extend from this area and connect to tendons which then attach to the bones in your hand and wrist. When you want to grip an object, the muscle contracts. In effect, it stabilizes your wrist and allows you to hold the object.

There will be tenderness specifically when you press the outside bone in the elbow called the lateral epicondyle. If when you lift your wrist against resistance and get pain in your elbow, you have confirmed this diagnosis.

There is no treatment for tennis elbow that produces immediate results. Rest and avoidance of activities that produce pain are important. I also recommend ice massage. Freeze water in a small paper cup then massage the outside part of the elbow in small circular motion until it feels numb.

Stretching exercises of the affected muscle are also very important. Straighten your elbow, then with the noninvolved hand slowly bend the involved wrist and hold it in this flexed position for about a minute. Repeat this a couple of times. It is helpful to use ice massage after this.

Your physician may offer you anti-inflammatory medication and if your problem persists an injection of a corticosteroid. Physical therapy can also help to reduce pain, and restore flexibility and strength. You also may get some pain relief by wearing a strap just below the elbow.

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15. My friend fell and broke her wrist. Why did the doctor put her in an external device instead of a cast?

The key to getting a broken (fractured) bone to heal is immobilization and there are three ways to accomplish this. The most common treatment is a cast. Casts are made of plaster or a more durable, and sometimes colorful, fiberglass material. Casts provide good, but not great, support. Grab your forearm tightly with your other hand and you will find you can still twist and move it. While a skilled orthopaedic surgeon can mold and configure the cast to provide protection and support, sometimes it just is not enough.

Internal fixation is another way to immobilize a fracture. Sometimes metallic devices within the body hold the broken bone fragments together. Imagine fixing two pieces of wood together. You could use screws, nails, rods, or plates. Take, for example, the thighbone (femur). If you cut it in half you will see it has the configuration of a soup bone with a strong outer shell and marrow middle. Frequently a fracture of this bone is fixed by putting a rod down the middle literally skewering the major fragments. Sometimes a fracture is fixed by using a plate that goes on the surface of the bone and bridges the fracture. Screws then hold the plate to the bone.

The last way a fracture can be immobilized is with an external device. This is especially valuable if there is an open wound which would be hidden by a cast, or if the bone is osteoporotic and tends to collapse. Pins are inserted through the skin usually at right angles to the bone fragments. An external bridge then connects these pins providing excellent stability. There is no more pain associated with this method than a cast. Your friend had this type of fixation.

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16. My doctor told me that I have damage to the cartilage surfaces in my knee joint. Can this be repaired?

When the cartilage surface in a joint is damaged you may have pain, swelling, stiffness and a catching, or grinding, sensation. Cartilage surfaces normally are smooth and regular, like the surface of a ball bearing. Imagine a ball bearing that has a divot or roughness in its surface. It simply would not function in a normal smooth fashion. Similarly, if you had a chondral (cartilage) defect, your joint would not function, as it should.

Many tissues in your body can repair themselves. If you cut yourself, your skin readily heals. Even if you scratch the cornea of your eye, it will heal. Unfortunately the cartilage that covers the bones in your knee simply cannot repair itself.

Orthopaedic surgeons have developed a variety of techniques to stimulate the damaged joint surfaces to achieve some degree of repair. Much of this is possible through arthroscopic surgery. This type of surgery is done using incisions about a quarter of an inch in size, so patients experience less pain and can return to normal activities very quickly.

Sometimes the arthroscopic technique is used to wash out loose debris in the joint. Other techniques involve making holes or abrading the exposed bone surfaces so blood vessels will bring in cells that will be converted to new cartilage. Though frequently excellent results are achieved, this new cartilage does not have the same wear characteristics as normal cartilage.

In another procedure cartilage plugs are taken from another part of the knee and transplanted to the defective area. This is similar to the hair transplant except that the plugs are put right next to each other. Still another technique involves harvesting normal cartilage cells, culturing them in a laboratory for about 4 weeks, and then putting them into the defect.

Certainly, a variety of things can be done to help your knee. An orthopaedic surgeon will be able to discuss the alternatives that are best suited to your particular problem.

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17. My orthopaedic surgeon recommended a Total Hip Replacement where one of the components is cemented in place. What is bone cement?

A Total Hip Replacement is one of the most common orthopaedic surgeries done today. When medication and rest no longer relieve the pain associated with arthritis, then a joint replacement should be considered. This basically is a procedure where the ends of the bones, that come together to form a joint, are resurfaced typically with metal and plastic components. In a total hip, the socket (acetabulum) and the ball (head of the femur) are replaced.

These implants must be fixed to the existing bone in some way. There are two basic ways to achieve this. One way is to use bone cement. The implant is cemented in place with methylmethacrylate, also used to make Corian countertops. A second way is to use a type of implant where the bone firmly attaches itself to the metal component. This process is called “biologic ingrowth.” Porous-like surfaces are incorporated into metals like titanium, which encourage this process.

An orthopaedic surgeon must consider many factors in deciding which method has the greatest chance of success for each individual patient. Age, weight, activity level, osteoporosis and bone strength are some of these considerations. Both components may be cemented, both may be by biologic ingrowth, or a hybrid system of one of each may be used. A skilled surgeon will have a success rate of over 95% and the new joint will last 15 to 20 years.

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18. I stepped off a curb inadvertently 3 months ago and sprained my ankle. Why do I still have pain and why does my foot feel unstable when I walk on uneven surfaces?

One of the most common orthopaedic injuries is the ankle sprain. When you turned your ankle you stretched the ligaments that hold your ankle bones in place. In mild sprains the ligaments are only partially torn. If you take a rope and stretch it to the point that a few of the fibers in the rope tear, this is analogous to a mild sprain. In a moderate sprain more of the fibers are torn, and in a severe sprain all of the fibers are torn.

Normally even the most severe sprains heal and become pain-free within 6 to 8 weeks. There must be another explanation if you are still having pain after 3 months.

One common cause of persistent pain and the feeling that your ankle is unstable could be that the ligaments did not heal as tightly as desired. If you walk on irregular terrain and your foot turns sideways a little, the ligaments simply do not hold the bones together. Your doctor should be able to detect this by manual testing, or he may take an x-ray while he holds your foot in a turned position to see how well the bones are held together. This is called a stress x-ray.

Another cause of your persistent pain and instability could be Sinus Tarsi Syndrome. This is an injury to the structures just below the bone on the outside of your ankle. Typically a patient will have pain and the feeling of instability when he or she walks down stairs and on uneven surfaces, and will have specific point tenderness over the sinus tarsi. Physical therapy or injections of cortisone may cure the problem, but sometimes surgery is necessary.

Still another cause of your persistent could be osteoarthritis, which is some extra wear and tear of your ankle joint as a result of the trauma. You might have some inflammation of this joint that will respond to anti-inflammatory medication. In any case, the symptoms you describe are not expected with a simple ankle sprain and you should see your doctor for further evaluation.

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19. I developed pain and swelling in my knee and my doctor said it is related to my psoriasis. Can you explain?

Psoriasis is a non-contagious skin condition that affects about 7 million people in this country. Raised reddened patches of skin covered by white flaky areas characterize it. Commonly it affects the scalp, elbows and knees. It usually appears between the ages of 15 and 35, and affects more women than men.

An abnormality of the immune system causes this condition. When you have an infection, your immune system produces cells and chemicals to fight it. For an unknown reason your immune system affects your skin cells and causes them to mature faster. The skin normally produces cells that mature and then slough in about one month. In other words, the skin you had a month ago is now gone. In areas where you have psoriasis, the cells mature in only 3 to 4 days and pile up on each other.

One third of the cases seem to have some hereditary predisposition, but in no particular pattern. Stress, infection, trauma, and certain drugs seem to trigger its onset.

Arthritis is an inflammation of a joint. Arthritic joints can be swollen, stiff and painful. Whereas osteoarthritis is caused by wear and tear, psoriatic arthritis is caused by an abnormality of the immune system.

Psoriatic arthritis can manifest itself in a number of ways. The classic type, which occurs in about 5 percent of patients with psoriasis, affects the finger joints closest to the nails. Pitting and lifting of the nails is frequently noted.

Other types of psoriatic arthritis affect the knees, hips, ankles, or wrists. It can be mild and respond to medications, or be progressive and result in the need for joint replacement surgery.

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20. When I developed an infection in my arm that did not respond to oral antibiotics my doctor insisted that I be hospitalized for care. What was he so concerned about?

Your doctor was probably concerned about a rare but sometimes fatal infection caused by bacteria that rapidly invade and spread through the skin and subcutaneous tissue. Physicians who care for this problem call it “necrotizing fasciitis” though you may have heard about “flesh eating bacteria” or “galloping gangrene.” The rapidity by which this infection spreads has led to widespread concern by physicians and the public.

A small laceration, minor burn or insect bite can introduce bacteria into your skin, which can lead to a soft tissue infection. Symptoms may include swelling, redness, and pain. If your system and antibiotics cannot fight this infection, a necrotizing infection may ensue. With the spread of this infection other systems of the body are affected resulting in breathing difficulty, kidney failure and hypotension.

No single bacteria is responsible for this condition. Though strep bacteria are commonly found, there usually is more than one kind. Certainly antibiotics are important to treat this condition. Surgery to remove all of the infected and necrotic tissues usually has to be done repetitively to prevent its spread.

These infections are more common in persons who have underlying medical problems such as diabetes, peripheral vascular disease, liver disease, or any other chronic illness. The mortality rate in spite of aggressive treatment is over 10%.

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21. For the past few months I have had pain in my thumb when I write, turn a doorknob and do needlepoint. What can I do?

Pain in the thumb is a very common problem in people from 50 to 70 years of age. The most common cause is degeneration of the joint at the base of the thumb. This problem occurs in approximately 1 of 4 women and 1 of 12 men.

There is a joint at the base of the thumb, which is very close to the wrist. This joint can degenerate just as a knee or hip. When the ligaments holding a joint together become lax, the joint will become loose. We know that unstable joints degenerate faster.

The human thumb is called on to perform a great number of functions and movements. Normal grasping and pinching functions place a lot of stress on this joint. One’s vocation or avocation can lead to the wear and tear physicians refer to as basal joint arthritis of the thumb.

The pain can be quite severe and can be brought on by writing, turning doorknobs, turning keys, using scissors, opening jars and any other activity where the thumb is used.

The initial treatment includes limiting the use of your thumb and a course of oral anti-inflammatory medication. A thumb splint may be helpful. A splint that immobilizes the wrist but allows the thumb to move is not helpful. A cortisone injection can give significant, but temporary, relief. Using a larger diameter pen and larger golf grips can help. If conservative treatment fails, surgery is considered.

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22. My doctor says I am at risk to develop osteoporosis. Why?

Osteoporosis is a disease in which bones become progressively weaker and as a result are more easily broken. Normally when you take a step off a curb, the hip bone is able to withstand this relatively small stress. If you have osteoporosis, the hip bone may not be strong enough and may break (fracture). The vertebrae in your spine ordinarily support the weight of your body, but if you have osteoporosis your vertebrae may compress without any trauma. This is called a compression fracture. Approximately 10 million people in this country have osteoporosis and 18 million more at risk to develop this condition. You are not alone.

Bone is a living dynamic tissue. It is constantly being produced and resorbed. If the rate of resorption is faster than the rate of production, then osteoporosis results. There are 2 parts of a bone: the hard outer shell and the marrow. In osteoporosis, the shell becomes thinner and the marrow becomes less dense. Imagine a sponge where the holes become bigger and the actual sponge material becomes less. This is what osteoporotic bone looks like.

One of the most important risk factors is hormonal. In women, menopause results in a decreased production of estrogen, which is responsible for the balance of bone production and loss. Men with a low testosterone level are also at risk. White and Asian woman are at higher risk than other racial groups. If you have relatives who have osteoporosis you are at greater risk.

Weight bearing exercise such as walking, dancing, hiking promotes strong bones. When I put a cast on an extremity for treatment of an injury and then x-ray the extremity a few weeks later, it is easy to see that the bone is less dense. We call this “disuse osteoporosis.” To have strong bones, you have to use them.

Lifestyle choices also affect the strength of your bone and rate of bone loss. Heavy drinking and smoking reduce bone mass. If your diet has been low in calcium and vitamin D, you will also be at greater risk for osteoporosis.

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23. I am 60 years old and am in reasonably good health. How much exercise should I get?

There are 4 basic topics I need to address in order to answer your question: exercise frequency, intensity, duration and type of activity.

First of all you should exercise 3 to 5 days each week. The intensity of your work out should raise your heart rate to about 70% of its maximum. To find your heart maximum heart rate, subtract your age from 220. Since you are 60 years old your maximum rate would be 160. Your target heart rate would be 70% of 160 or 112. During your exercise simply check your heart rate by taking your pulse. If you take your pulse for 10 seconds, multiply this by 6 to get the heart rate for 1 minute. If your heart rate is slower than 112 pick up your pace a little. If it is faster slow your pace down.

The duration of your exercise should be between 20 and 45 minutes. Moderate intensity of longer duration is recommended for the non-athletic adult. The goal is to promote the supply and use of oxygen, also called “aerobics.” Aerobic exercise promotes the efficiency of the oxygen transport system. Your lungs will become stronger, your heart will slow down and pump with greater efficiency, and your body cells will utilize oxygen more easily.

Any activity that uses large muscle groups in a continuous and rhythmical mode is appropriate. Running, jogging, walking, swimming, bicycling, and cross country skiing are some of the activities you can pursue. Weight training is not an aerobic exercise. Tennis, racquetball, and softball are aerobic but only for bursts at a time. Be sure to check with your medical doctor before pursuing any exercise program.

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24. I have pain and swelling on the outside of my foot just before my little toe. What can I do?

Prominence of the bone on the outside of your foot just before the little toe can result in pain and swelling called a “bunionette.” This is on the exact opposite side of your foot from where you would have a bunion. Chronic irritation caused by friction between an underlying bony abnormality and constricting footwear results in thickening of the bursa and skin. When it becomes painful it is called a bunionette.

This can occur as an isolated deformity but frequently is associated with other foot problems. Two thirds of the patients with a bunionette will also have a very flat foot. Sometimes a person with a very wide foot with a lot of space between the bones will develop this condition. Women or men who wear shoes that overly constrict the forefoot are prone to develop this condition.

The most important treatment is to wear shoes that fit well and do not apply pressure to the painful area. Certainly if you lived on an island and walked without shoes in the sand all the time you would have no problem. Unfortunately, our weather and culture do not permit this.

If pain is persistent then surgery can be considered. The goal of surgery is to fix the prominent bone that causes the deformity. Many different procedures are done depending on the severity of the problem and the judgment of your surgeon. It could be as simple as shaving off part of the bone, or more complicated as cutting the bone and changing its angle.

A bunionette is a very simple problem that can result in a lot of pain and disability. Relatively simple non-surgical and surgical remedies are available.

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25. I have terrific pain in both of my knees. Will glucosamine and chondroitin help my arthritis?

More than 70% of the population over 65 years of age has evidence of “wear and tear” type arthritis called “osteoarthritis.” The cartilage surfaces that cover the end of the bones wear out much like the rubber on your tires. Bone on bone is the ultimate result.

Biochemical changes occur in the cartilage that predispose to deterioration and loss of this cartilage. A number of medications are being studied that may decelerate degredation or actually aid in the repair of the cartilage surfaces of a joint. It is hoped that glucosamine and chondroitin sulfate will have these effects

Glucosamine and chondroitin are constituents of normal cartilage. In healthy cartilage there is a balance between its build up and breakdown. In the wearing process, breakdown occurs faster than the build up. The proponents of glucosamine and chondroitin feel that this imbalance can be restored. The skeptics feel that taking these medications is akin to eating hair to restore hair to a balding head.

The majority of clinical studies done thus far have shown that glucosamine and chondroitin reduce the symptoms of arthritis at least in the short term. Long-term effects have yet to be studied. These medications work for some, not all sufferers. If you truly have osteoarthritis, taking medication produced by a reputable manufacturer may give you some relief but not cure your problem. Adverse reactions are infrequent, gastrointestinal problems being most common.

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26. What is a meniscus? My doctor told me I have a torn meniscus and need arthroscopic surgery.

A knee joint has two types of cartilage. One type of cartilage covers the bones that come together to form the knee joint and is called articular cartilage. It is smooth and lubricated by the joint fluid.

The second type of cartilage, called the meniscus, is wedge-shaped. Imagine a bowling ball sitting on the ground. If you wanted to keep it from rolling you might devise a wedge that wraps around the base of the ball. Your knee joint is formed by your thighbone that is rounded at the bottom and the top of your leg bone, which is relatively flat. The wedge-shaped meniscus wraps around the joint periphery to help stabilize the joint.

The configuration of the meniscus also helps to distribute the joint fluid that provides lubrication and nutrition to the articular cartilage. Some of your weight is also transmitted through the meniscus so it acts as a cushion.

Prior to about 25 years ago surgeons removed the entire meniscus when it was torn. (Total menisectomy) This corrected the immediate symptoms but the knee joint wore out a lot faster causing arthritis. Today we try to repair the meniscus or remove as little as possible. This preserves its function and prevents the usual wear and tear we observe with a total menisectomy.

A tear of the meniscus may cause pain, swelling, popping, clicking or buckling. Unfortunately the meniscus rarely heals without surgery.

Surgery is done through small incisions. Your orthopaedic surgeon can look into your knee joint with an arthroscope through a quarter inch incision. He also has tools that are smaller than a quarter inch to do what is necessary to relieve your symptoms. This is called arthroscopic surgery.

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27. I began to have pain in my shoulder while serving in tennis. Now I have pain when I move my shoulder and even at night. What’s wrong?

You describe a very common scenario where there is some inflammation or even tearing of a tendon called the “rotator cuff.” The rotator cuff connects muscles from your shoulder blade to the round part of your upper arm bone, called the humeral head. These tendons grab onto the humeral head just as you grab onto a round doorknob. Imagine trying to grab and turn a doorknob with only 2 or 3 fingers. You simply do not have the mechanical advantage to turn the knob easily. When the rotator cuff tendon is injured and its integrity is affected, your muscles cannot function effectively to rotate your shoulder.

In addition to a weakened ability to move your shoulder, you can have pain. The pain will occur with certain motions of your arm, such as reaching overhead or behind you. You may experience pain further down your arm or into your neck. You may have pain even at rest.

The rotator cuff is often injured by repetitive overhead activities. That is why baseball pitchers notoriously have shoulder problems. The shoulder motion in serving a tennis ball, swimming, or even hanging curtains can result in this type of injury. Sometimes simply the shape of the bones in your shoulder will predispose you to develop a rotator cuff problem. A traumatic event such as a fall can result in a severe tear of the rotator cuff that requires surgery to repair.

Treatment for this condition is aimed toward decreasing inflammation, healing the tendon fibers and regaining muscle strength. Rest from aggravating activities and use of anti-inflammatory medication is very helpful. Injections of cortisone and physical therapy also may play a major role in your recovery. Surgery is sometimes required.

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28. Every morning when I begin to walk I experience severe pain on the bottom of my heel which tends to improve as I walk. If I sit or rest for awhile the pain will recur when I walk again. What can I do?

Pain at the bottom of the heel is one of the most common foot problems. One usually attributes this to a heel spur, but this rarely is the cause of this problem. The actual cause is inflammation or tearing of a band of tissue, called the plantar fascia, which stretches across the bottom of the foot.

In order to help maintain the arch of your foot there is a strap-like band that connects the heel bone to the toe portion of your foot. This functions just like a bowstring to help maintain your arch. Walking causes more tension on this band. Sometimes it will become inflamed or tear where it attaches to the heel bone and cause pain. We call this plantar fasciitis.

Do not expect to be cured of this condition quickly. Ice massage followed by stretching can be very helpful. Massage your arch and heel with ice using longitudinal strokes for 10 to 15 minutes. Follow this by stretching the plantar fascia. To do this, place the ankle of your affected foot over your opposite knee. Using your hand, stretch your arch by pulling your toes and ankle backwards until you experience a tight feeling. Hold this for 2 minutes. Repeat this routine several times each day.

Another way to treat plantar fasciitis is to wear a splint that holds your ankle bent backwards while you sleep. We call this a night splint. Frequently, this condition responds to an injection of a corticosteroid into the region of pain. Oral Anti-inflammatory medication and physical therapy are also helpful.

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29. I heard that heart defibrillators are now available on airplanes. What do they do and should they be available at other public places?

250,000 people die suddenly from cardiac arrest each year in the United States. The heart can develop an abnormal rhythm called ventricular fibrillation. In this condition the heart muscle contracts erratically instead of in a consistent rhythmical pattern. Therefore, blood does not get pumped to vital body parts such as the brain. A person cannot survive in this state more than about 5 minutes.

Obviously, it is important to recognize and treat this condition as soon as possible. An electrical device, called a defibrillator, produces a shock that can restore the heart to its normal rhythm. Initially, only physicians used defibrillators in the hospital setting. In the 1980’s emergency medical technicians were trained to use defibrillators out of the hospital.

An automated external defibrillator (AED) incorporates a microcomputer that can analyze the victim’s condition and advise the rescuer if a shock is indicated. Thus a “first responder” can safely use this device. Within the past few years AEDs have been placed in airports, airplanes, hotels, shopping malls, schools and other public places.

Three fourths of all cardiac arrests occur in the home and 60% of these are witnessed by another individual who could use an AED. Should these devices be available and disseminated through one’s community? Is the money better spent on exercise programs, high blood pressure treatment, smoking cessation, and health education? As the price of AEDs decreases, these issues will come to the forefront.

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