More Dancer Problems...

Dancers pretty much abuse their feet, with repetitive forces in unnatural poses, so it is no surprise that they end up with stress fractures in their feet. When we think about broken bones in the foot, most of us picture a broken toe or a large bone in the middle of the foot (the metatarsals). However, there are two tiny pea-like bones that can also be broken- the sesamoid bones. These little bones are embedded side by side within the tendon that is in the ball of your foot, just beneath the base of your big toe. They act like pulleys, allowing the tendon to slide more easily as you bend your foot, pushing off with running, jumping or walking. Stress fractures of the sesamoid bones show up as gradually increasing pain every time you put pressure on them, especially with the act of bending and pushing off. The pain tends to stay very localized, is relieved with rest, and the maximal tenderness to touch is underneath the base of your big toe.

How are these fractures diagnosed?
Sesamoid fractures, like all stress fractures, may not show up on x-rays till they have been present for a couple of weeks. A dark line is seen within the white "ball" that is the sesamoid bone. Occasionally the sesamoid bone will be completely broken into two parts, and these fractures may require surgical correction.

What is the treatment?
There is no quick fix for this problem, much to the dismay of dancers (and runners). The treatment is to stop bending the ball of your foot, most easily accomplished with a firm walking boot. How long? Typically a minimum of 3 weeks, but more often roughly 6 weeks. Upon return to activity, the key is to "start low and go slow"- do NOT jump back in to full workouts!

BOTTOM LINE: For deep, persistent, worsening pain under the ball of your foot, consider the possibility of a stress fracture of your sesamoids- head to your family doctor for an exam and possible X-ray.

Dancer Problems...

Have you ever had a plantar wart? These are the warts that show up as a painful bump underneath your foot. These unwelcome growths often show up at the site of "trauma", so dancers obviously most frequently develop them on their feet or toes. Warts are incredibly common, with a prevalence of up to 10% of Americans. In fact, the vast majority of us will develop at least one wart somewhere on our body during our lifetime.

Are warts dangerous? Not really. Warts do not turn in to cancer, and in fact, untreated, will eventually go away on their own. The problem is that "eventually" could be years. Since warts are rather unsightly, and obviously plantar warts can be painful (picture having a pebble under your foot as you walk), most people do not choose to do nothing and simply wait out the wart.

How can you get rid of a plantar wart?
There are many different remedies out there, most of which have some success- including the perennial favorite, duct tape. Over-the-counter fixes may work as well as treatments in your doctor's office. None are perfect. One relatively recent study from 2011 again demonstrated that home daily self-application of salicylic acid yielded the same results as a physician treating in the office once with cryotherapy (liquid nitrogen). EVerT: cryotherapy versus salicylic acid for the treatment of verrucae--a randomized controlled trial.

My personal favorite treatment for plantar warts is a non-prescription product called Curad Mediplast. This stick on product is a combination of higher dose salicylic acid (the active ingredient in most OTC liquid wart removers) and, well, tape. You simply cut a tiny piece large enough to just cover your wart, and stick it on your freshly washed, but thoroughly dry wart. Leave it on for 24 hours. Take it off, scrub your wart a bit with soapy water and a pumice stone or washcloth, then let dry for 10 minutes and place a new one on. Repeat this for ONE week. Then, do nothing for two weeks (you can continue to use the pumice stone if you want, but don't be tempted to start digging around with sharp objects. Repeat the week-long cycle again. Smaller plantar warts like the one pictured above may resolve after only one cycle, while larger ones may take three or more. Just remember- one week of treatment, then two weeks off. Is this 100% evidence-based practice? No, but it has been successful for my patients, and correlates with clinical studies using similar protocols.

BOTTOM LINE: Think you have a plantar wart? Head in to your family doctor to confirm the diagnosis and start on a treatment that will get you back to action as quickly as possible.

Is it Ebola? Or "just" the FLU?

You have a fever, chills, sore throat muscle aches, headache, nausea and vomiting…is it Ebola Virus? Or perhaps that new respiratory virus (Enterovirus 68)? While technically speaking, it is possible for your illness to be caused by one of these dreaded agents, the odds are very much against it. However, you very well may have the FLU.

NOW is the time to get your flu vaccine- please! The flu vaccine is recommended for EVERYONE aged 6 months and older (who does not have a contraindication for the immunization.) We are already seeing cases of flu here in Austin, as others are across the United States. Instead of fretting about the two cases of Ebola virus here in Texas, recognize that last year in Texas alone, twenty children died from the flu. Twenty. Children. Gone. And, according to the CDC,  across the United States we have over 23,000 deaths and over 200,000 hospitalizations from influenza.

"But Dr. Grimes, the flu shot always gives me the flu!"
No, it does not. The flu shot does NOT contain live virus- it is not capable of causing influenza. In randomized, blinded studies the only difference between people who got a placebo (salt water) vs those who receive the actual flu vaccine is that the real vaccine makes your arm more sore for a few days.

There are no absolutes in medicine, but I will share that in my 20 years of practice, 99% of my patients who have actually HAD a real case of influenza make it a priority to get a flu shot each year so they don't have to experience the flu again. This is not a perfect vaccine, but annual flu vaccines greatly reduce your chance of getting the flu, and definitely decrease the severity of the infection if you end up with influenza.

BOTTOM LINE: The CDC recommends ANNUAL FLU VACCINE for everyone* over the age of 6 months. I got mine- did you get yours yet?

(*Flu vaccine is not indicated for the minority of people with "severe, life-threatening allergies to flu vaccine or any ingredient in the vaccine. This might include gelatin, antibiotics, or other ingredients. ")

Shake, Pump & Fives!

The American Journal of Infection Control has the media world abuzz with talks of fist pumps vs. handshakes today, as they released a recent study confirming that a quick greeting of fist pumps "substantially reduce" the transfer of bacteria between people (compared with shaking hands.) This investigation confirms previous similar studies, such as the 2013 report from the Journal of Hospital Infection, Reducing pathogen transmission in a hospital setting Handshake vs. fist bump: a pilot study.
We know that fist bumps (and high fives) are typically very brief- less than a second, versus hand shakes that can last for several seconds. Additionally, there is less skin to skin contact in a fist bump. However, these studies have shown that hand shakes pass more bacteria from person to person than you would expect simply based on time and area of contact. Fist pumps, it turns out, are up to 20 times more hygienic than hand shakes.

As a primary care physician, I have long greeted children with high fives, and switched to fist pumps as they became trendy over the last few years. With adults, I have primarily used the traditional handshake- but I literally wash my hands in the exam room in front of the patient (to ease any concerns they might have of me bringing in germs from the patient before them.) Everyone knows that washing hands reduces the spread of germs, and most people are vigilant about this within the health care setting or in restaurants. However, what about the rest of our busy lives? If you bump into a friend or business partner at an event, and they introduce you to the group of people they are with, what is the healthiest way to greet these new people? Do you shake hands, but then whip out your hand sanitizer and pass it around? Or perhaps, based on these studies, do we replace the handshake with a fist pump? There are, indeed, researchers suggesting "handshake-free zones" in healthcare settings.  And what about hugs? Does this more intimate gesture pass more germs, or because we are only touching clothing (and avoiding skin-to-skin contact,) is that safer?

Personally, I think the real take home message here is a reminder about the importance of HAND WASHING. Choose high fives and fist pumps (or smiles and nods) when those are socially acceptable alternatives, and especially if you are feeling ill. If you have the opportunity to wash your hands, don't skimp! How long should you wash? 20-30 seconds (much longer than the usual speedy dash of hands through the water en route to grabbing a paper towel that we see in public restrooms.) Use soap and make it foam up, scrubbing especially under rings and around the finger nails. If you use sanitizer, be sure to use enough that you still have 20-30 seconds of "scrubbing".

BOTTOM LINE: Good hand hygiene is the MOST EFFECTIVE way to limit the spread of germs from person to person- choose fist pumps or high fives before handshakes when appropriate, and mainly, remember to wash your hands early & often!

 

Jellies!

My last blog was about INVISIBLE things that sting, but this one is all about much larger and visible stingers- JELLY FISH. We all know what they look like- bell-shaped, primitive looking soft tops, with variable amounts of tentacles streaming below. Swimmers typically stumble upon these creatures at or near the surface of the water, or washed up along the beach. Do NOT make the mistake of thinking an obviously dead jelly fish washed up on the shore is harmless! The stingers (nematocysts) in the tentacles will release their toxin and sting you- whether the jelly is dead or alive. 

Most jellyfish stings around the United States are an uncomfortable nuisance, but not life-threatening. The box jellyfish of Australia, however, can be lethal, and so these are a true medical emergency.

What happens with a jelly fish sting, and what should you do?

Stings cause immediate pain, redness and swelling. Severe stings can cause more bodily reactions, including, nausea, vomiting, headache, muscle aches, and fever/sweats/chills. Immediately wash the stung area in SALT WATER- stick it in the ocean. If you rinse with fresh water, remaining nematocysts will discharge, which means you will immediately have many more stings! If you have quick access to vinegar, pour that over the sting (because vinegar helps neutralize the toxin and prevents further release of more toxin.) Stings typically involve extremities, but if your eyes or mouth are involved with the sting, seek immediate medical attention. For the eyes, flush with a gallon of fresh water before heading for help. 

If the tentacles are stuck on you, pour vinegar over them, then make a paste with mud (or if available, with baking soda or shaving cream) before you try to remove the tentacles with tweezers or a knife/razor. Flush the area again with vinegar after removal. 

Topical steroid cream or ointment may help reduce discomfort and swelling after the initial first aid.

BOTTOM LINE: If you are going to swim in an area known to have jelly fish, make sure everyone knows not to touch "dead" jellies, and add a bottle of vinegar and a box of baking soda to your family beach bag.

Invisible Things that Sting...

The crystal clear waters beckon you, and you blissfully leap into the water ready to search for playful Honu (sea turtles) and brightly colored fish. Suddenly something stings your arm...and then your leg and your other arm. Are there jellyfish? No. In fact, you see absolutely nothing, yet SOMETHING or things are continuing to sting you. Have you baked your brain in the sun too long?

The picture above is from the Na' Pali coastline in Hawaii. While snorkeling there, a small group of the swimmers (including myself and one daughter) were bothered enough by invisible "stings" to get back on the boat. Meanwhile the majority of snorkelers were completely fine, despite swimming right next to other people who were being stung. Back on the boat, mosquito bite-looking lesions appeared everywhere we felt stings, with some people having a great deal of surrounding redness and swelling. The red bumps continued to sting like a moderate bee sting for ten minutes or so, then simply seemed to react like a mosquito bite- more itchy than painful. Our mystery stings lasted a few days, then disappeared.  

There are numerous names for rashes that crop up after swimming- sea bather's eruption, ocean itch, and my personal favorite, sea lice, to name a few. What causes these invisible stings?  Ultimately, some type of larval parasite burrows into a human instead of reaching its desired host (usually a water bird).  These larvae come from corals, sea anemones and thimble jellyfish. These parasites cannot live, grow or reproduce in human skin, so they die. Unfortunately, in many people, their presence sets off an allergic reaction- hence the red bumps and itch. With more intense allergic reactions, swimmers can develop headache, body aches, GI symptoms and fever. Primarily what is seen, however, are itchy red bumps or blisters.

The medical name for this type of rash is cercarial dermatitis. If the stings occur on exposed areas, there are typically fewer total red bumps. However, often sea bather's dermatitis shows up beneath where a swimsuit covered the skin, because the larva can get trapped in the fabric. Swimmers can have literally hundreds of bites covering their torso.

What can you do? If you start to feel bites, remove your suit BEFORE you shower- fresh water often triggers the larvae to sting. Vinegar may neutralize the toxin and reduce additional stings- apply to your body and rinse your swimsuit in the vinegar as well.

Additional treatment is targeted at the allergic reaction. Consider taking an oral antihistamine such as Benadryl, Claritin, Allegra or Zyrtec, and apply topical steroid cream or ointment on your torso or extremities (not on the face or genitals). Cool compresses may also help ease the itch or burn.

Is this rash contagious? Absolutely not- each bump is an allergic reaction to a larva burrowing into the skin, and the larva cannot be spread from one person's body to another. However, if you borrowed a wet swimsuit from a friend, any larva trapped in the suit material could certainly sting you.

BOTTOM LINE: Itchy, burning stings or bites after swimming is a frustrating allergic reaction, but only rarely medically "scary"- simply remove your suit as soon as possible, rinse with vinegar if available, take an oral antihistamine and/or use topical steroid cream on torso or extremity lesions and your symptoms should resolve within days to a couple weeks (depending on the severity.) 

Worried about Dementia? Try Something New...

This week, JAMA Neurology offered an encouraging study for our aging population which demonstrated that continuing to stimulate your brain through intellectually challenging work or leisure activities (such as playing a musical instrument, using a computer or reading) can postpone the onset of dementia. The investigators utilized nearly 2000 participants in the Mayo Clinic Study of Aging, specifically enrolling people aged 70-89 years old, and identifying whether or not they had APOE (a genetic marker linked with increased risk of Alzheimer's disease) and assessing their baseline cognitive performance.

People who had less mentally challenging occupations, less late-life intellectual stimulation and/or weaker educational backgrounds scored lower on the baseline cognitive assessment. Those people with more advanced degrees or continued late-life education scored higher, creating the anticipated advantage of "cognitive reserve"- in other words, they start with more brain power, so they can afford to lose more brain function before dementia is diagnosed. (For the visually-minded, imagine that dementia is diagnosed when the elevator gets below the 10th floor. If you are starting at the 21st  floor, you get there much later than someone who's elevator started at the 11th floor.)

The surprising good news from this study is that regardless of your baseline brain power, life vocation or genetic predisposition for Alzheimer's disease, everyone's memory power benefits from intellectual stimulation after age 40. In fact, this study showed that the intellectually stimulated people postponed the onset of dementia beyond 7 years compared to their peers who did not mentally push themselves.

Of note, there were observed positive snowballs- the more education a person has on the front end, the more likely he or she is to continue a lifetime of intellectual stimulation.

Does it matter what type of intellectual stimulation? We don't know for certain, but psychologists will be the first to tell you to pick what you ENJOY, because you are far more likely to keep it up. Remember that what you enjoy may or may NOT be what your aging friend or parent enjoys…so whether it is learning to knit, playing the piano, learning a new language or even learning how to text on an iPad- push yourself to learn something that sounds interesting to YOU.

Special kudos to my amazing mother-in-law, Bene, for not only continuing to reading medical articles long beyond her nursing career, but for her constant willingness to learn anything! She texts faster than most adults (with far fewer spelling errors than the rest of us), and even learned to add emoji's last month. Pictured above is the two of us taking a "selfie" from her iPad.

BOTTOM LINE: Until we have a cure for Alzheimer's on the treatment end, the "ounce" of prevention  we all need is to STIMULATE our brains…and never stop!