Got a medical question? Let me stretch my brain.

As many of you probably know....I am a physician type. Family medicine more specifically. Military to be even more specific.

Well, I am involved in a constant effort to keep my clinical knowledge up to date, and less rusty. I read/listen to many sources, developing/maintaining my skills to stay at the level of a "competent generalist". In the military its a bit tough though because my patient base is just too healthy until they get blown up, then its mostly meat and bone carpentry and then shuttle quickly to the surgeon.

So, I help my friends (thats all of you) alot (probably more than most other physicians). A) it helps my skills, B) it hopefully helps out my friends, C) because of my situation (doc starving for the challenge in the face of healthy patients) it helps me feel better about myself. D) I am an attention whore.

Thus, I thought it might be good to open up a thread where you, my BOTLs/SOTLs, can throw out some concerns and I can see what I can do.

Disclaimers:
1) I can't promise you specialist knowledge. Depending on the question I may throw down what I already know and leave it at that. Or, maybe I will research it to a level I am happy with and then throw down what I have learned. Or, maybe I won't have much to put down about it and that is what you will have to settling with.

2) Anything I throw down here is to be taken for what it is....someone you don't really know (for all many of you know I am a 12 year old pretending to be a doc), fielding questions I may not be qualified to answer. NEVER take what you read here as gospel. If its serious, if its important, you should still see your doctor.

3) I am not always available. I get shipped around alot, spend long times without internet access. I am also orchestrating a big career change in the next 7-8 months (releasing from military, developing a civi practice, renovating a house, parenting children, being a good spouse, selling/buying a house, moving, prepping for the new practice). If I am not responding, maybe I never will.

4) This thread is an experiment. If life gets out of hand or things get too crazy in this thread I may abandon it. I will probably make that known though before it happens.

5) Once again...this thread should not count as your only medical consultation. I cannot refer you to specialists, I cannot determine the "all important" aspects of the situtation without actually being present with you. You probably don't realize how much of medicine is about the intuitive aspects of this situation. Body language, physical traits, they way things get said in a face-to-face encounter have HUGE importance in the evaluation of the situation. I could easily miss major important elements simply by not being in the same room with you, watching you as you describe your issue. Certainly physical exam is impossible, as would diagnostic testing. Finally, I can't start treatments, or even guarantee I will discribe the treatments best suited; once again, intuitive reasoning goes a long way here.

6) This is an advice column. Most advice columns are full of BS. Don't expect more. While I try to stay current and "evidence based", medicine is too big for everything to be based on well-worked out science. As a generalist I try to keep up, but its all too much, so my evidence based knowledge is going to be pathetic in orthopedics compared to an orthopedic surgeon. Its always possible that I may spout out "establish wisdom" in a sub-field of medicine that has already been proven wrong 10 years ago.

Scared you away yet?

And, with that, shoot out your questions and I will see what I can do. Ultimately this is probably going to take the form of a banter thread (in certain ways).

Cheers

Cy

PS: three out or every two people don't know how to handle statistics. Even worse, five out of four people misquote their statistics. I am no different. But, I take stats with a grain of salt. Telling you that condoms are 97-99% effective means that I don't really have the number memorized and that I don't really see the need to more accurate than that anyway....it means condoms are good (unless you are trying to stop herpes, which case they are only 30% effective)

[Rabidsquirrel]

Why does it hurt when I press *here*?


Sorry, had to do it.

I think it might be the pointy tips of the asterisks. That's probably why it hurts.

[Whee]

Well, we know you;re not a 12 yo. If you were, you'd tYpE lIkE tHiS and talk about boobies and comic books...

[Rabidsquirrel]

Originally Posted by illinoishoosier

talk about boobies

If that's a qualifier I think a lot of us are in trouble.

I'll give ya a whirl Cyanide.

My right knee has no ACL or medial meniscus. I don't have any trouble with the stability of my knee. It has never "popped" again, and it doesn't limit my ability to be active when I want to. I can play squash, hike, climb, etc. I didn't get ACL replacement as I felt it unnecessary.

However, I have noticed over the last year or so that it takes greater effort to get up from a crouching position and my knee aches a little more than usual. It's not a big deal, but I'm not getting any younger.

Would the ACL replacement surgery help with this?

[Old Sailor]

Originally Posted by kayaker

I'll give ya a whirl Cyanide.

My right knee has no ACL or medial meniscus. I don't have any trouble with the stability of my knee. It has never "popped" again, and it doesn't limit my ability to be active when I want to. I can play squash, hike, climb, etc. I didn't get ACL replacement as I felt it unnecessary.

However, I have noticed over the last year or so that it takes greater effort to get up from a crouching position and my knee aches a little more than usual. It's not a big deal, but I'm not getting any younger.

Would the ACL replacement surgery help with this?

Ian.....it's called Old Age!

Originally Posted by kayaker

I'll give ya a whirl Cyanide.

My right knee has no ACL or medial meniscus. I don't have any trouble with the stability of my knee. It has never "popped" again, and it doesn't limit my ability to be active when I want to. I can play squash, hike, climb, etc. I didn't get ACL replacement as I felt it unnecessary.

However, I have noticed over the last year or so that it takes greater effort to get up from a crouching position and my knee aches a little more than usual. It's not a big deal, but I'm not getting any younger.

Would the ACL replacement surgery help with this?

Hey Ian;

The knee is kind of funny, in that there are a number of conditions that can look identical in symptomology. And further, they respond equally well to conservative therapies. But, once they start not conforming to said therapies, then you have to get specific in order to approach the surgical options. That's where MRIs come in.

But, it was reasonable to not repair the ACL, and it may be reasonable to now re-examine the issue to see if things should be approached differently now.

All that said, in the military I find many a soldier with your exact story. Heck, my knee is almost identical in story as well. What it probably boils down to in this case is something called Patellofemoral Pain Syndrome, also known as Chondromalacia Patellae. This is where the knee-cap doesn't track through the groove at the end of the femur (upper leg bone), and as a result gets torn up pretty bad. It leads to stiffness and pain after long periods of sitting (this is called the "moviegoers sign"). What is causing this mis-tracking is a mis-alignment of the tibia (lower leg bone) in relation to the knee. This in turn is commonly cause by fallen arches (either obvious; or "dynamic" where you only see the collapsing inwards when you shift from non-weight baring to weight baring). As the foot collapses inwards, the tibia is slightly angled inwards, meeting the femur at the knee at a slight angle. Now the kneecap tries to jump-rail when the leg is straightened.

I commonly see this in knees where some of the other structures are damaged. This decreases your "physiologic reserve" to compensate for the fallen arches (by simply pulling everything into place through brute strength) and the mal-alignments are allowed to unveil themselves.

So, what do you do?

1) Increase that physiologic reserve by a) strengthening all the muscles groups or b) repairing that ACL (but you can't repair the meniscus)

2) grab some good sturdy orthotics (I find generic, off the shelf ones are best because they are relatively cheap which makes it easy to replace when they wear out, roughly at the same rate as a pair of running shoes), and have a look at how old the soles of your shoes are. People find their knees start to hurt more as their shoes age.

When you get back to Edmonton here I will have a look.

Cheers

John

[Fumes]

This is a long shot, but any ideas will be greatly appreciated.

Every once in a while my wife has crippling lower back spasms that are triggered by simple things like bending over or getting out of a chair. They aren't frequent, but when they happen she has pain to the point where she can barely move. It usually takes a full day of rest and heat on her back before she can get out of bed. And ibuprofen. Lots of it. She has taken muscle relaxants for this but they don't seem to work any better than Advil. X-rays show she has narrowing discs, but her doc isn't sure that is the problem. She tried chiropractic for several months but it hasn't been effective in the long term.

That's the background. My question is this: she had a spasm yesterday (just getting off the couch) and afterward she had numbness and tingling in her legs and in her arms from the elbow to the fingers. This was new and it went away after a few hours, so we're not too worried about it, but I'm wondering if it gives us any new ideas as far as diagnosing the cause of her back spasms. Maybe it was just a reaction to the pain?

Thanks for any suggestions, Doc! Great idea for a thread!

[gettysburgfreak]

I sprained my ankle pretty bad in PT almost a month ago and it is still a little bit swollen. It doesn't really hurt that much any more but the fact its still swollen has me wondering if it is just because I am constantly on it doing vigorous activities and don't have a chance to rest it, or could it be something more serious?

Originally Posted by Fumes

... I'm wondering if it gives us any new ideas as far as diagnosing the cause of her back spasms. Maybe it was just a reaction to the pain?

Thanks for any suggestions, Doc! Great idea for a thread!

What studies are showing us is that we really don't have a strong grip on the cause of many cases of chronic (or in this case, recurrent) back pain. Reasonable clinicians are starting to dismiss the discs as the cause of all back-pain (and really limitting it to the rare occassions where the discs are actually pressing on nerves).

But, that doesn't leave us with many convincing stories to tell. And, it leaves it up to us to create a compelling fiction to fill the gaps. I just so happen to have one of those "compelling fictions", good enough that I have even convinced myself that it may have validity.

Many back injuries will result in some muscle damage, either from the actual trauma or from the huge muscle contraction you exherted to try to avoid the trauma, pulling the muscle. When the muscle heals, well it heals with scar tissue instead of regenerated muscle fibres (muscle-building is a different process)

Scar tissue has a number of characteristics:

1) its never stronger than 70% the tissue architecture it replaced
2) It has no contractive function, its not a muscle
3) It shrinks over time. Look at any scar on your skin, if its large enough it will have a puckered edge, it shrank (you could easily find exceptions to this)
4) It is heavily innervated with pain nerve fibres.

So, what this leads to is a case where, the moment a scarred muscle starts to fatigue too much through heavy strain (twisting while carrying something) or through prolonged use (like sleeping in a bad position), it lengthens under load, surpassing the length of the scar, the weak scar starts to tear, sends off massive numbers of pain signals to the central nervous system. In a reflex loop, signals short circuit back to the muscles to tell them to go into a massive contraction to protect themselves under load and then this loop just keeps cycling on itself.....resulting in muscle spasm.

Finally, imagine all the other nerves that have to traverse from the spine to the periphery. They have to pass around and through all the structures in between point A and point B. Scars love to entangle anything near them as they develop. Its not unreasonable to think that some of these nerves could get caught up in the scar tissue, and thus get tethered down to nearby muscles. As the muscles go into spasm, they wrench on everything attached to them, including the nerves. Nerves don't work well under mechanical tension and thus the numbness would occur. You wouldn't feel the nerve geing stretched. But you would feel odd sensations/pain in the area of the body the nerve served. The brain doesn't know anything about where the nerve travels, only what regions it innervates.

Hope this is helpful..

Cheers

John

[newcigarz]

Originally Posted by illinoishoosier

Well, we know you;re not a 12 yo. If you were, you'd tYpE lIkE tHiS and talk about boobies and comic books...

hey I like boobies and comic books.

[Whee]

Originally Posted by newcigarz

hey I like boobies and comic books.

You are not alone.

[elderboy02]

Thanks for offering to help us out!

[acarr]

Thanks for the offer. Maybe a little off the traditional medicine question, but a general practitioner is going to get a number of questions pertaining to non-traditional medicine. So here goes:

Can you tell me whether or not you think turmeric/curcumin is an effective anti-inflammatory spice.

Originally Posted by acarr

Thanks for the offer. Maybe a little off the traditional medicine question, but a general practitioner is going to get a number of questions pertaining to non-traditional medicine. So here goes:

Can you tell me whether or not you think turmeric/curcumin is an effective anti-inflammatory spice.

Wow, this is going to be fun. I am going to tackle this one first, then once I am done baseboards in the bathroom I might tackle some of the orthopedic questions.

OK, checking through pubmed rather quickly I noticed a review of all available data regarding this directly. Curcumin, which is believed to be the "active component" of Turmeric does seem to have some ability to alter gene expression in animal chondroblasts (cartilage progenerator cells) and is seemingly believed to have some anti-inflammatory effect. Some caveats though would be that, as a supplement, having to go up against the GI system and then the liver before it gets into the blood, its unlikely to show any objective anti-inflammatory benefit systemically. The review article does note that further, properly designed studies need to be conducted before it should be advocated for treatment of inflammatory conditions (this usually means that the available data consists of small crappy studies [SCS] that are not statistically powerful enough to prove anything; to see into the truth, bigger studies with rigid controls are needed). As an aside, osteoarthritis is no longer believed to be a true inflammatory condition and so, this is probably why we aren't seeing much benefit from anti-inflammatories in general (it seems to be more of an analgesic effect we are getting from the drugs).

So, bottom line....in cell cultures it might be beneficial, but the delivery method is probably going to get in the way of experiencing any "real" benefit to the person. That being said, if you believe it helps, and it isn't itself causing you any harm....then its reasonable to give it a shot. Just don't take too much of it, as any ill effects in the face of unlikely benefit is a net decrease in quality of life.

Cheers

John

[mosesbotbol]

Originally Posted by acarr

Thanks for the offer. Maybe a little off the traditional medicine question, but a general practitioner is going to get a number of questions pertaining to non-traditional medicine. So here goes:

Can you tell me whether or not you think turmeric/curcumin is an effective anti-inflammatory spice.

Interesting as I am turmeric crazy in my cooking. I put it in just about everything. I know it is common to mix tumeric in milk when giving to children (in India).

[s15driftking]

how do you cure scalp feliculitis, noting that a 10% panoxyl soap bar has gotten you no where?

Originally Posted by s15driftking

how do you cure scalp feliculitis, noting that a 10% panoxyl soap bar has gotten you no where?

I haven't seen much scalp folliculitis. It is interesting that it is being treated with a benzyol peroxide solution. If it were a limitted, easy to get to area, I would treat it with something like polysporin or mupirocin (sp?) twice a day for 10 days. If that didn't work or if it were a hard to get to area (like a hair covered scalp) then I would go more for a system (pill) antibiotic like cloxicillin or erythromycin. All that said, I would certainly take a second look at it before concluding its a bacterial infection of the follicles on the scalp. I would be looking for another diagnosis (like pustular seborrheic keratosis) or an underlying cause and treat that.

If it were hard enough to treat I would certainly go ahead and swab it and await lab results to determine if it were anything more problematic than a typical skin-borne bacteria causing it.

[Cenookie]

First of all thanks, a couple months ago I was helping a friend move furniture when I felt what I can only describe as a warming sensation and pain in my shoulder. I immediately lost strength in my shoulder. In fact I wasn't able to put my truck in gear to drive home. My shoulder only hurts when I move it a certain way. And at night in bed it's not a pain like in the muscle, but more of an ache. I can massage it and fell no sore spots, but move it a certain way and PAIN.