Doctors are supposed to be superhuman. We rarely take time off during the 3-7 years of training (“Illness doesn’t take a Holiday”). Vacations are rare because they put extra stress on fellow residents, who are left to do the same amount of work with fewer hands.

Over the last 10 years the safety factor for patients has been highlighted. Doctors in training make more mistakes when tired than when well rested. But, the health of the training doctor is often overlooked.

I am conflicted in my thoughts. Watching patients over an extended period of time is invaluable experience for a doctor. Training as a doctor is essentially learning pattern recognition. Reading it in a book is not adequate. The experience is essential. But this valuable experience often comes with an extreme lack of sleep that can lead to dangerous mistakes

With this in mind, here are a few tips for doctors (and other adults) to get the best sleep possible.

• Strive for 7-8 hours of uninterrupted sleep a night, at a routine time every night
• Sleep in a quiet, dark room
• Avoid exposure to light a few hours before going to sleep (falling asleep to the T.V. is a bad habit)
• Exercise early in the day
• Avoid caffeine and sugar within 3 hours of bedtime

Sleep is essential for health as well as the learning process. We need to balance the learning experience with an adequate amount of sleep that allows doctors (and those in training) to be at the top of their game.

There are several reasons why bunions develop:

1. Congential. Some people are born to develop bunions
2. Trauma. Striking the inside of the big toe can tear the supporting ligaments and permit the malalignment to develop
3. Shoewear. This is the most common cause.

There is no getting around it. Shoes cause a repetitive microtrauma to the forefoot ligaments. Feet are supposed to spread apart as we stand but most of our shoes are designed to push the toes together. High heels further exaggerate these forces and position all of the body weight on top of a smaller area.

Don’t get me wrong, I think high heels look great, but they do cause harm. So what’s a girl gonna do?

Like everything in life, moderation is the key. Here are a few tips to cut down on the risk of bunions while wearing heels:

• Wear them for short periods of time
• Never walk long distances in them
• Always give your feet a break
• If you can, avoid dancing in heels. It’s beautiful, but dancing puts even more pressure on the forefoot.

Most importantly, use common sense when you buy shoes. If they hurt in the store, put them back. Pain is your foot’s way of saying: “You are stretching me, please stop.” Do your body a favor and listen to it.

On May 18th, Jones bruised his left leg after being hit by a rogue ball. He was placed on the disabled list shortly after. During the procedure on Saturday, doctors drained 120 cubic centimeters of blood from the leg to speed up the recovery process. Contusions like this usually heal by themselves eventually, but can take some time.

“I feel so much better now,” Jones said. “It was throbbing. It let me know with everything that I did. Now, we’ve relieved a lot of the pressure down there and I can’t feel my heartbeat [in the ankle] anymore.”

Dr. Silverman Comments

A Contusion occurs when an area within the body that has been exposed to direct blow bleeds underneath the skin. A hematoma (blood clot) forms in the area of a contusion.

Most contusions are treated with observation as they tend to resolve on their own. However, intramuscular contusions can cause problems as they are painful, block motion around nearby joints, and may lead to scarring and a troublesome condition known as Myositis Ossificans (Bone in the muscle). Very rarely is surgery recommended as it was in this case. The well known condition of limb-threatening compartment syndrome can develop from unchecked bleeding into a compartment. If the bleeding is not stopped through decompression, the entire leg can be lost to necrosis.

Jones claims his doctors told him that surgery would decrease his recovery time from this injury. I believe that surgery was indicated for reasons of impending compartments syndrome. The comment, “Now, we’ve relieved a lot of the pressure down there and I can’t feel my heartbeat [in the ankle] anymore” clearly indicates that a tourniquet like condition had developed in his leg. He is lucky his doctors were so aggressive in treating this problem with surgery before it worsened.

Related Sources:

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Specifically, Hewitt had a procedure known as a toe fusion, wherein bone spurs are removed and two screws and a metal plate permanently lock the toe into place.

The toe has been giving Hewitt problems for some time. It was riddled with arthritis and misshapen after years of constant impact on the tennis court. Ideally, this surgery will allow Hewitt to play pain-free and give him another shot at winning a title.

Dr. Silverman Comments

Hewitt underwent a fusion of the first metatarsalphalangeal joint. This is the large joint of the big toe, an area that commonly becomes arthritic. The degenerative change is known as Hallux Rigidus (or a stiff big toe).

Everyone agrees that treatment of this condition starts non-surgically with stiff shoes that don’t rub on the toe. But this rarely allows athletes to return to sport, it just makes the condition a little more comfortable.

When the condition becomes more advanced, surgery is recommended. This is where the disagreement begins. As an orthopedic surgeon, fusion of the joint is my last choice as there are other much more functional options. If the arthritis is mild, the spurs are removed, but it seems like Hewitt’s condition was much more advanced.

In this situation, whether the patient is an athlete or not, I perform a great toe soft tissue arthroplasty. This procedure uses specialized bone cuts and the patient’s own tissues to recreate a joint. It has a great success record and keeps great toe range of motion and strength.

As a last resort, you can always fuse the toe but there is no turning back from this.

Related Sources:

AFP

The injury occurred on Thursday while the team was training. Nicks fractured his right foot during individual runs. He is scheduled to have surgery on his fifth metatarsal today. The procedure consists of placing a screw into the broken bone and giving the fracture time to heal.

Nicks’ orthopedic surgeon predicts a 12 week recovery period following the surgery.

Dr. Silverman Comments

Fixing the fifth metatarsal is usually quite straightforward.

Fractures of the base, when significantly displaced, need a small screw placed across them. They heal rapidly within 4 weeks. Patients are able to walk on it right after surgery and running can begin very early. The media reports that Nicks will be out much longer. This leads me to believe he sustained a much more serious fracture.

Fractures that are just a few mm further towards the toe, in the area of poor blood supply are called “Jones” fractures. They need very different treatment. Non-surgical treatment healing rates are abysmal, require extensive non-weight bearing for 6 weeks in a cast, 4 more weeks in a weight bearing cast, and return to sport is delayed up to 15-18 weeks. Most patients refuse that option.

Surgical treatment of a Jones fracture includes placement of a long 5-6.5mm thick rigid screw straight down the shaft of the fifth metatarsal. It is a technically challenging procedure to do well. Being off by a few degrees can result in misalignment of the fracture or even creation of a worse fracture.

I love fixing a Jones fracture – they are some of my favorite orthopedic surgeries. I use Minimally Invasive Surgery, so healing is faster. Getting that screw right down the center is a great feeling. The best part is knowing that the patient can weight bear right after surgery and thus get back to sports sooner.

Related Sources:

Huffingtonpost.com

Granger sprained the ankle in the second quarter when he rolled off of LeBron James’ foot after throwing up a jump shot. He rolled it again in the third quarter and left the court for the remainder of the game.

“It’s definitely not a high ankle sprain, thank goodness” said Granger. “It’s just a regular ankle sprain. It has swelling in it. We’ll tape it up, put an ankle brace on it, and I’ll get out there.”

Despite his ankle swelling to “softball” size, Granger started game 6 last night, but his ankle still plagued him and prevented him from keeping LeBron James under wraps. Ultimately the Heat beat the Pacers, shutting them out of the playoffs.

Dr. Silverman Comments

Like most basketball players, Granger has had foot and ankle issues before. In 2009, he tore his plantar fascia and sat out for several weeks.

Rolling off of another player’s foot is one of the most common ways to sprain an ankle. But how does the history of a plantar fascia problem affect him?

The plantar fascia is a strong thick ligament on the bottom of the foot that extends from the heel to the toes. It acts as a static support of the arch. When the plantar fascia tears it often does not return to full function. While many people run and play impact sports after a plantar fascia tear, the heel remains mildly tender. The tenderness is worst along the inside of the heel (medially). People may walk with an accentuated lateral heel strike. Players land with greater force directed outward. This puts them at risk to sprain.

Related Sources:

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The study examined the BMIs of 150 overweight or obese patients who had successful ankle fusion or replacements. Researchers found no significant change in BMI 6 months, 1 year, and 2 years after surgery as compared to pre-operative BMI.

Many overweight people blame their weight problem on their feet and ankles, sighting them as the reason they can’t exercise and work off the excess weight. This study shows that weight problems are most often not the result of unstable ankles and feet.

Dr. Silverman Comments:

It is of no surprise to me that following an ankle fusion or ankle replacement, people don’t lose weight. Every day patients tell me the weight they have gained is because their foot or ankle hurts and they can’t exercise. I tell them, their activity levels have very little to do with why they gained weight. Intake of food beyond what is required to sustain is what causes weight gain.

Having surgery so you can lose weight is often a bad idea. Behaviors are hardwired and take extensive planning and determination to correct. There are many ways to exercise that don’t require weight bearing that can keep activity levels up, but the best way to lose the weight is to eat the right foods.

I follow and recommend my patients start on a Paleo diet. The diet is simple—Don’t eat anything that is processed or fed something that was processed. Eat lots of fruits and vegetables, some naturally raised meat or wild caught fish. Don’t eat grains, legumes, or animals fed grains and legumes. And of course you need to control sugar intake too.

Related Sources:

jbjs.org

ACS is usually caused by trauma such as fractures or crush injuries. It involves excessive pressure within a muscular compartment. Normal resting muscle pressure is 12-20 mmHg. In compartment syndrome, the pressure rises to over 30mmHg and squeezes off the blood supply to the muscle, causing the muscle and the nerves that travel in that compartment to die. The condition is incredibly painful and if not treated with emergency surgery within 6 hours, the muscles and nerves die from lack of blood flow.

Acute Compartment Syndrome is most common in the lower leg, and in high energy injuries, but can also occur in the foot, the thigh, the forearm, and the hand. Compartment pressures can even cause an acute carpal tunnel syndrome by increased pressure following a wrist injury.

The injury is easily diagnosed by a standard clinical exam. The skin over the compartment will appear tight, shiny, and swollen. The most important sign is pain with passive stretch of the muscles. Knowing when the pain hurts from compartment syndrome and when it hurts from a fracture is the challenge—this is where it’s essential to have an experienced orthopedic surgeon taking care of you.

While an MRI can help, it is a waste of valuable time. MRIs are expensive tests that can take more than 2 hours to coordinate. In this condition, minutes count.

Some doctors use a pressure catheter inserted into the muscle compartment. These devices are tricky and inconsistent at times. If they are positive, you have your diagnosis, but a negative test is not reliable.

The condition is treated with emergent fasciotomy. Long relaxing incisions are made and the fascia (a layer of tissue beneath the skin and over the muscle) is released. The wounds are left open, and a wound vac (vacuum suction device) is placed over the open wounds. This encourages rapid resolution of swelling. Once the swelling is resolved, the wounds can be closed. Sometimes, the swelling is so great that skin-grafting is required.

But collaboration between patient and doctor is absolutely essential for successful treatment. Doctors need patients just as much as patients need doctors.

Dr. Silverman Comments

Shared decision making is the hallmark of Silverman Ankle & Foot.

During each patient visit I sit down with the patient and their family to discuss treatment options. After we’ve discussed their case, I provide a diagnosis and treatment in a clear and understandable manner, tailored to each patient’s needs.

I explain the risks and benefits of the following three options:

• Option 1: Live with it and do nothing. This is a very important option to leave on the table when the condition will not cause eminent bodily harm. Understanding this option lets patients come to other treatment decisions without pressure and on their own time schedule.
• Option 2: Non-surgical treatment. This option lets patients try to accommodate while the body attempts to heal or become accustomed to the disorder. Sometimes this means longer recovery times with lower risks; sometimes this means temporizing a condition until a later date; sometimes it is futile but it gives the patient a better sense of control of their destiny. I encourage non-surgical treatment in many cases.
• Option 3: Surgical treatment. This is often the most conservative option for those patients who want rapid recovery and best overall function after treatment. A strong understanding of the previous two choices is necessary to consider this option.

I have my bias since my education, experience, and on-going study has taught me what works and what doesn’t. I do not assume an authoritarian role unless I hear the line of fear—”Whatever you think is best, Doctor.” Only then do I make explicit demands of my patient. They must help me to make the decisions as they need to be as invested in their care as I am. Regardless of their choice, I stand with the patient on their decision and help guide them to the best of my abilities.

According to Lawson, following the bunion surgery it was too painful for her to walk to the fridge. As a result she had to ask people to go to the fridge to get food for her, which made her more conscious of how much she was eating.

But bunion surgery was likely not the primary reason for the weight loss, according to orthopedic surgeon Dr. Lance Silverman.

Dr. Silverman Comments

This is a cute story, but the weight loss is more due to a newfound habit, rather than bunion surgery. Lawson decided that asking others to help her eat made her more conscious of what she was eating. This enhanced understanding led to better choices during her recovery.

As for recovery from bunion surgery, the recovery is not nearly as bad as advertised, at least not with the way we manage patients at Silverman Ankle & Foot.

Elevation and strict bedrest for 23/24 hours per day is critical during the first 3 days. After that, patients use pain and swelling as their guide. A compressive dressing helps control swelling. This dressing is changed during the first week, and then a removable compression splint is applied.

Most of my patients walk immediately after surgery in a simple post operative sandal. As soon as tennis shoes or hard soled clogs will fit, they are recommended to use them. By 6 weeks, I expect bone healing and return to sport or walking.

People worry incessantly about the pain. I tell them, “This is not your mother’s bunion surgery.” Bunion surgery is painful only during the first 1-2 days after the procedure (the time we control pain with narcotic medication). After that, symptoms recede quickly.

Related Sources:

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