High Heeled Danger!

Attention female shoe lovers- if your closet is packed with high heels, especially those with pointy toes,  you may one day find yourself dealing with a medical problem known as a Morton's neuroma. A Morton's what, you ask? Morton's neuroma- a little balled up group of nerve endings (perineural fibrosis, if you want the medical lingo) along the small digital nerve as it passes between your toes, most commonly in the space between your third and fourth toes.

This malady is most common among women in their mid to late 40's. High heels cause more weight to be transferred to the front of the foot, and the pointy toes squeeze in from the sides, pinching in on the nerve, causing inflammation. Often the patient first notices the problem as a sensation of a pebble in their shoe, but typically this progresses quickly to pain, cramping, numbness or shooting sharp pains of the area with weight bearing. Can you get a Morton's neuroma without high heels? Sure- anyone who "overuses" their feet- ballet dancers, basketball players, runners- can develop this problem, but high heels greatly contribute to this problem.

How is a Morton's neuroma diagnosed? Xrays might be obtained if there is concern of a stress fracture or other bony issue, but the neuroma itself does not show up on xray films. Often this condition is diagnosed based on your history and a thorough exam, but occasionally clinicians use ultrasound to further evaluate the problem. Ultrasound is very accurate at identifying neuromas (98% sensitivity) but not always accurate (65% specificity). MRI scanning is rarely needed to help with surgical resection, for resistant cases.

How about treatment? First and foremost, it's time for "sensible" shoes- wear flat shoes with a roomy toe box. Inserts such as metatarsal pads may help ease symptoms, as well as arch supports for those people with flattened arches. Taking NSAIDS (ibuprofen or naprosyn) often will ease the discomfort temporarily, and nearly half of patients (40-50%) will respond to these simple measures within three months. The primary treatment from the medical end when conservative measures are not effective enough, however, is a steroid injection into the top of your foot (just above where the pain is located). This injection may be repeated in 1-4 weeks if there is a partial response.  Another 40-50% of patients will respond to these injections. For those 20-25% who continue to have pain despite all these measures, surgery may be indicated to go in and remove the actual neuroma and free up some space (releasing a ligament) in between the toes, and happily around 96% of surgical patients obtain relief.


BOTTOM LINE: Once again, prevention is key! Enjoy your high heels in moderation, but consider a more generous toe box and wedge (less slope) for daily use if your profession calls for dress shoes. Also, go see your family doctor when you START feeling that "pebble"- don't wait for it to become intense daily pain!

Cigarettes- the Good News & the Bad News

Let's start off with the GOOD news- the CDC's anti-smoking TIPS campaign has turned out to be far more successful than they had dared to hope! Over 1.6 million smokers had a quitting attempt, and at least 200,000 smokers DID QUIT as a direct result of the shocking pictures and stories featured in this unique national program. The Lancet published a wonderful article this week summarizing all the findings: Effect of the First Federally Funded U.S. Antismoking National Media Campaign.

I have always maintained that stories are more powerful than statistics. Sure enough, this campaign is chock-full of stories from former smokers- people sharing extremely painful negative consequences from their nicotine addiction. Virtually every complication from smoking is shared: heart surgery scars, asthma, artificial limbs (from damage to blood vessels), artificial voice boxes (from throat cancer), COPD (chronic obstructive pulmonary disease) and of course, lung cancer, to name a few. Hearing from Terrie- a former cheerleader, points out the dangers of "social smoking" in college. Likewise with Michael, who smoked in the military. Click on the TIPS from Former Smokers 2013 to hear and see more...and share with any of your friends or family or co-workers who still smoke.

The campaign goals are to increase public awareness of both immediate and long term health risks of smoking- both first-hand, and from inhaling second-hand smoke. Note that for every person who dies from smoking, 20 more Americans are LIVING with a smoking-related illness. The CDC wants to encourage and support smokers who are ready to quit, as well as encourage them to limit other people's exposure to their second-hand smoke. 

So that was the good news...now the bad. Just last week, Notes from the Field: Electronic Cigarette Use Among Middle and High School Students- United States, 2011-2012 was published in the CDC's Morbidity and Mortality Weekly Report. E-cigarettes are not a new cell phone app, they are true electronic cigarettes that are battery powered and deliver nicotine and other byproducts via an aerosol. Worse yet, they can add sweet "childhood" flavors- fruit, mint or chocolate. Really??? Does the industry have NO conscience???? Not surprisingly, they are portrayed as "safe smoking" (anyone else reminded of "safe sex" campaigns?) and teens are jumping on board. E-cig use doubled in this time period, yielding nearly 2 million (1.78, lest I exaggerate) students trying out nicotine in this delivery system last year. Please note that although we do not yet have long-term studies on the "pure" damage of these e-cigarettes, we know that nicotine is damaging to adolescent brain development and, hello- nicotine is ADDICTIVE. If you get addicted via e-cigs vs. dipping vs. "regular" cigarettes- the outcome is the SAME. You are ADDICTED to NICOTINE.

BOTTOM LINE: There is still NO AMOUNT of smoking that is GOOD for you, so please, help encourage your friends who are already smoking to QUIT, and parents, please warn your kids that e-cigarettes are NOT SAFE. NICOTINE is ADDICTIVE in ANY FORM.

Fruits Helping Diabetics?

Hooray! I was delighted to see a new study about the role of dietary fruit in diabetic patients, entitled
Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies, published this week in the British Medical Journal (BMJ).  Over the years, I have found that many of my diabetic patients purposefully avoid all fruits, fearing that the sugar in fruits will raise their blood sugar values and worsen their diabetes. However, fruits are a wonderfully nutritious part of a healthy diet, and I will forever attest that eating too many fruits or vegetables is NOT the major contributing factor to becoming diabetic or overweight.

This particular study reviewed diets (based on scheduled food questionnaires), and found that for every three servings per week of whole foods consumption of blueberries, prunes, grapes and raisins, apples and pears, bananas, grapefruit, and even peaches and apricots,  the risk for developing diabetes was significantly REDUCED!

Fruits are packed with wonderful nutrients, phytochemicals, vitamins and fiber, all of which have long been known to help prevent untoward health consequences such as heart disease and cancer. Hopefully this new study will help convince everyone that FRUIT belongs in the pre-diabetic and diabetic diet as well. The key to improving diabetes in overweight or obese people is weight loss: consuming fewer calories than you burn. Colorful diets packed with fruits and vegetables are the best way to get you moving that direction.

Of note, drinking fruit juices was actually associated with a slight increased risk of developing diabetes. Once again, we see that eating the WHOLE FRUIT is better than making it into a juice or condensing it into a pill...

BOTTOM LINE: Up your intake of whole fruits, especially blueberries, grapes, raisins, apples, prunes and pears, and decrease your risk of developing diabetes. 

Golfer's Elbow- the "Inside" Elbow Problem

Tennis elbow refers to the "outside" elbow pain of lateral epicondylitis. However, if your "inside" elbow is hurting, you may have GOLFER's elbow, known medically as medial epicondylitis. Both elbow problems are due to overuse injuries, and rarely do they occur in both arms at the same time.

Tennis elbow is much more common than golfer's elbow, with tennis elbow having a little over 1% prevalence, and golfer's elbow only 0.4%. Golfer's elbow is an overuse of the wrist as it flexes and pronates (turns palm down). Interestingly, tennis players with overly tight grips often end up with "golfer's elbow".

The main symptoms of golfer's elbow are pain on the inside (tender to touch and aches most of the time), worsened pain with resisted flexion and turning the palm downward, and worsened pain with gripping or handshake. The pain starts at the bony bump on your inside elbow and then may radiate downward to your forearm and wrist.

Once again, treatment includes relative rest (stop the repetitive activity that is worsening the problem), anti-inflammatory medications, compression wraps and icing. An ice massage is done by rubbing the ice in a wide circular motion over the painful side of your elbow for about 5 minutes. (Making the ice in a small paper cup will save your fingers from an uncomfortable session- just peel away the top part of the cup and then you have a paper holder.)

Symptoms that do not resolve within a week or two using these basic treatments may require formal physical therapy or steroid injections to fully resolve the problem.

BOTTOM LINE: Don't let overuse injuries of your elbows keep you off the courts or links- start treatment as soon as you begin to notice persistent elbow pain, and avoid developing full blown "tennis" or "golfer's" elbow.

Tennis Elbow- Racquet Optional!

Recently I talked about carpal tunnel syndrome and cubital tunnel syndrome of the wrist. Now I'd like to move up a notch and talk about issues with the ELBOW. Interestingly, we've got two different "sport" elbow problems- tennis elbow and golf elbow-and yet, you can develop either of these problems without ever picking up a racket or a club. Today, let's talk about tennis elbow.

The medical name for "tennis elbow" is lateral epicondylitis, and this occurs when the tendons on the outside of the elbow are torn or strained. Typically the symptoms begin with an ache on the outside of your elbow, that gradually worsens until it becomes an intense burning pain that is worse when you grab or twist anything (opening car doors, jars, lifting groceries, etc.)

What causes tennis elbow? Any action that causes a repetitive movement can cause swelling and pain in the joint being used, and tennis elbow is no exception. In this case, the movement is a repeated twisting of the wrist and elbow, such as in a tennis stroke. However, other activities- like hammering, sawing, giving massages or working in an assembly line-can also cause "tennis" elbow.

Do kids get this? Not too often- the typical patient with tennis elbow is 30-50 years old, with an equal distribution of men and women.

Do you need an X-ray? An x-ray will not "show" tennis elbow, but some times an x-ray is done to rule out an underlying fracture.

How is tennis elbow treated? There are multiple things to do to treat tennis elbow, but the most important is relative rest- not a cast, but avoidance of the activity that caused the problem. Additionally, taking consistent over-the-counter anti-inflammatory medications such as ibuprofen or naproxen will help reduce both the pain and the swelling. Ice packs applied a few times per day, especially after activity, will also help. An ACE wrap can help control swelling, plus serves as a reminder to you not to overdo it! If these treatments are not enough to resolve the symptoms, then physical therapy, splinting and steroid injections are the next level of treatment. Rarely, surgery is required.

Prevention: If you are taking up a racquet sport (or joining a league and greatly increasing your time on the court), make sure to maintain good strength and flexibility in your arm muscles with light weights or resistance bands.

BOTTOM LINE: If you are developing persistent "outside" elbow pain, you might have "tennis elbow"- try rest, ice, compression, and anti-inflammatories as soon as possible, but if it persists, it's time to see your family doctor.

PS- Happy August- change those air filters!

Say NO to Delivery Food!

Have your kids reached the "I'm bored" stage of summer yet? If so, why not spend some quality time together in the kitchen? Our family is challenged with one vegetarian and one GF (gluten-free) dieters, but we have found multiple menus that still please everyone. Today's meal (pictured above) was made by our younger teenage daughter, proving that 14 year-olds can definitely do more than order pizza!

Nutrition studies have found that kids are far more willing to expand their palate when they are involved in preparing the food. Fruit smoothies are probably the easiest and most delicious way to engage your child in the kitchen. Grab some frozen fruit, a banana, and some plain or vanilla yogurt. Toss the ingredients together in a blender and voila- healthy breakfast you can drink on the run as you dash off to dance camp!

My next favorite is today's dish-stir fry. This meal is simple to make vegetarian by adding your beans of choice, but can also be protein-enhanced with chicken, fish or other meats. Supervise your kids as they learn to chop up squash, zucchini, mushrooms, onions and carrots, then toss them in a large wok or pan and stir fry with olive oil. You can also add some garlic and other seasonings as they expand their palate. We serve this over rice (using the" toss in the microwave for one minute" super-fast option) or pasta or even simply over lettuce for an extra veggie load.

BOTTOM LINE: Break the pizza/burger/nachos summer habit, and substitute some healthy dishes and family fun in the kitchen!

Is this Carpal Tunnel Syndrome?

With all the time we spend at computers, I'm amazed we don't actually see more complaints of carpal tunnel syndrome (CTS), the single most common cause of peripheral nerve compression. Carpal tunnel symptoms include pain, numbness or tingling of your THUMB, INDEX, and MIDDLE fingers, and may extend to include your wrist, palms and forearms. Typically, the pain is worse at night, although that is not true for every person. Extended use of your wrists or hands- such as typing at a computer- also tends to increase discomfort.

The actual problem in CTS is pressure on the median nerve at the wrist. The median nerve only supplies the thumb "side" of the hand and fingers, which is why the symptoms do not show up in the pinky finger. (If the pinky is numb or tingling, you may be pressing on the ulnar nerve at the elbow).
The space in the wrist is limited- restricted by a ligament on the bottom and bones up above, so even general fluid retention and swelling can cause compression and lead to carpal tunnel symptoms. Pregnancy, for example, often results in enough fluid retention to cause CTS. Other risk factors include diabetes, kidney failure, low thyroid and birth control pill usage, as well as jobs or activities that result in prolonged flexion or vibration of the wrist, such as golfers, carpenters, musicians, jack-hammer operators and assembly line workers or grocery clerks.

There are a couple simple tests that doctors use to help diagnose CTS. Tapping on the underside of your wrist may cause a shooting electric pain to jump up into your wrist or palm- that is called the Tinel sign. Holding your hands together, bent downward (like reverse prayer hands) can worsen the numbness, pain or tingling in your thumb and first two fingers- this is the Phalen's sign.

Treatment obviously varies depending on the cause of the CTS. If the primary cause is fluid retention from another medical problem or medication, then treatment will target those issues. Prescription strength ibuprofen or similar anti-inflammatory medications have traditionally been used to provide relief of symptoms, although the scientific evidence is lacking to support this approach. Various splints are available and have been proven to provide some relief when worn consistently at night. Local steroid injections into the wrist have definitely been shown to be effective for at least short-term relief of symptoms (compared with placebo). Physical therapy and avoidance of behavioral triggers play a significant role in treatment. Finally, a minority of CTS cases may require actual surgical decompression to improve symptoms.

BOTTOM LINE: If you are having persistent or recurrent numbness, pain, or tingling in your thumb or first few fingers, head to your family doctor for a definitive diagnosis- don't wait until the symptoms have been stuck there for months, because the longer you've had symptoms, the more difficult it is to cure.