Archive for September 2009

Many athletes present to me with groin pain almost all saying they, “pulled [my] groin” and it’s not getting better. What are common causes of groin pain, when should you see a doctor and how is it treated?

Groin pain, that is pain where the abdomen meets the legs, can be cause by acute injury or wear and tear over time. Acute injury happens with direct blows, fall, sudden directional change or acceleration or some other kind of trauma.

More chronic overuse injuries happen with repeated day to day activity that puts stress on the anatomical structures in the groin area.

Groin Pain can also be referred from other parts of the body like the kidneys or intestines or reproductive system, so it is essential that if there is no obvious mechanism for your pain, you have to see your physician.

Ice Hockey, soccer, basketball and cross country skiing are common sports that put you at risk. Many groin injuries are also caused in work or home related injuries or motor vehicle accidents.

Pulled muscles, ligaments and tendons in this area can result of sporting or other causes of injury. Commonly, Injury is to the adductor group which stretches from your pubic bone to the femur. This group that helps pull your leg back in to your side from an outstretched position or from side to side.

If the injury is mild, localized aching pain in the inner thigh and groin can occur. If it’s a severe injury, sudden pain, swelling and bruising may occur as well.

Treatment is dependent on severity and cause. For this post, I’ll focus on the adductor group strain which is the most common. More so that other types of injury, rest is very important for groin strains. Many patients say they start to feel better, go back to the activity that caused it, but they reinjure it, putting them back weeks to months in terms of recovery.

Avoiding these exacerbating activities even when the pain goes away is critical. Icing and heat may also help for swelling and pain relief though heat should not be applied until the acute swelling phase of 48-72 hours is past. Physical therapy to incorporate various treatment modalities (ice massage, electrical stimulation and various exercises) can also help symptomatically in this early stage.

Further out, usually a least a week or two later, once pain free at rest, very gentle stretching exercises can help regain range of motion and flexibility though any pain is a bad sign and stretching should be discontinued.

Groin injuries to the adductor group can be recurrent so preventative hip adductor and abductor stretches and core and pelvic stabilization can help prevent future injuries.

If pain is persistent past a week or two, or if it is a child, it is very important to see a sports physician to rule out a sports hernia or other cause of groin pain.

References:

1) www.Uptodate.com
2) Lacroix V, Kinnear DG, Mulder DS, et al. Lower abdominal pain syndrome in National Hockey League players. A report of 11 cases. Clin J Sport Med. 1998;8:5–9.
3) Fan LJ, Spence RAS. Sportsman hernia. Br J Surg. 2000;87:545–552.

Health Reform Needed

Physicians and health activists like me have been trying to raise awareness for the fight against the obesity epidemic.  Health policy is obviously a hot topic, especially after Obama’s address to congress yesterday.  Not surprisingly, now leading health policy makers are taking up the charge. Below are excerpts from the STOP Obesity Alliance press release. Read the official release at the bottom of this post.

The two most recent Surgeons General of the United States, David Satcher, M.D., Ph.D., FAAFP, FACPM, FACP and Richard H. Carmona, M.D., M.P.H., FACS, today led the Strategies to Overcome and Prevent (STOP) Obesity Alliance in urging policymakers to take direct action in health reform to address obesity and the chronic diseases associated with it.

Dr. Richard H. Carmona, 17th U.S. Surgeon General, Health and Wellness Chairperson of the STOP Obesity Alliance and President of Canyon Ranch Institute says, “Obesity now impacts every aspect of our lives, including the future of our health care system. Health reform that directly addresses obesity will save lives, save money, and improve the health and well-being of every American.”

Dr. David Satcher, 16th U.S. Surgeon General says, that due to the complexity of the obesity epidemic, “Until we collaborate to address obesity through meaningful, population-based policies and programs, our nation will continue to be crippled by obesity and the chronic diseases it causes.”

The STOP Obesity Alliance released four targeted recommendations designed to improve the dialogue and interventions around obesity. The following elements should be included in health reform:

•    Standardized and effective clinical interventions, flowing from evidence-based guidelines, such as those approved by the National Heart, Lung and Blood Institute (NHLBI), that include acknowledging the health benefits of five to ten percent sustained weight loss to aid and support those individuals who are currently overweight or obese achieve improved health.

•    Enhanced use of clinical preventive services to monitor health status and help prevent weight gain, especially for individuals who are already overweight and are at risk of becoming obese.

•    Effective, evidence-based community programs and policies that encourage and support healthy lifestyles, focus on health literacy, address health disparities, and represent a significant investment in population-based prevention of obesity.

•    Coordinated research efforts to build the evidence for all three of the above elements, continuously improving quality of care, bolstering our understanding of what does and does not work in various settings, and helping to translate the scientific research into practice recommendations for real-world clinical settings and communities.

“Clearly, America cannot successfully reform the health system without addressing obesity,” said Christine Ferguson, director of the STOP Obesity Alliance. “While the situation is grave, the goal is attainable. The STOP Obesity Alliance recommendations provide a needed focus and a successful plan for health reform.”

See the full press release at:
http://www.stopobesityalliance.org/newsroom/press-releases/16th-and-17th-u-s-surgeons-general-stop-obesity-alliance-announce-america-has-reached-tipping-point-on-obesity-call-for-direct-action/

Yet another reason to lose weight if you are obese: obese women are more likely to have children with asthma.

A study from the Netherlands following 4,000 children from before birth to eight years of age. In the children with a least one parent with asthma, an obese mother increased the risk of asthma by 65 percent by age eight!

What is the link?  Obesity is a metabolic state with increased inflammation throughout the body. Excess fat produces inflammatory compounds called cytokines and reduces the effectiveness of natural anti-inflammatory cytokines.  In previous studies, cytokines have been proven to have a role in asthma development.

Obesity in pregnancy is also known to increase the risk for birth defects such as spina bifida, cardiovascular defects, cleft lip and palate, limb deformities, and hydrocephaly (abnormal build up of the fluid around the brain.)

So if you are of child bearing age, it essential to maintain a healthy weight as determined by your physician or health care provider. If you are pregnant already, talk with your physician about what healthy weight range should be maintained as losing weight during pregnancy is not advised in most cases.

References:

1) Presented at the International Conference of the American Thoracic Society, May 19, 2009 via www.healthcentral.com

2) Stothard, KJ. Journal of the American Medical Association, Feb. 11, 2009, vol 301: pp 636-650.

I will attempt to distill the complicated clinical decision of when to surgically repair your rotator cuff tear into a short post based on current knowledge.

The rotator cuff is a group of 4 muscles and tendons in your shoulder that helps to stabilize the shoulder and to internally and externally rotate as well as abduct and the shoulder. It can be injured with many types of trauma to the area, as well as overuse and degeneration of the cuff muscles and tendons and/or surrounding structures over time.

The indications for surgery include:  1) Acute loss of strength due to rotator cuff tear with healthy muscle bellies. 2) After failure of non-operative rehabilitation treatment and modalities for a chronic tear for 3-6 months.

What are the contraindications to getting the shoulder repaired? Tears causing no pain or decrease in function, frozen shoulder, or chronic “massive” irreparable tears should not be surgically repaired.  In addition, a surgeon may be unwilling to repair it if it is a chronic tear with little pain, longstanding weakness, or if the chief complaint is poor function.

With younger patients with rotator cuff pathology, the inherent quality of the muscle and tendon complex can be better, thus prompting many surgeons to surgically repair a tear in young people earlier.

The highly simplified goals of surgery are to cut out the tear margins, especially if it is frayed and degenerative, free up the cuff tear from any scar tissue that has formed, reattach the tendon to bone if necessary, and repair the tendon itself. The eventual goal is increased function and strength of the shoulder, decreased or resolved pain, and maintenance of as much safe range of motion as possible.

The surgeon may decide to operate with an arthroscopic approach using tiny cameras and instruments through tiny holes to repair the tear, or he/she may opt for a mini-open or a full open procedure. The approach varies depending on the tear, patient and surgeon. You must talk with the surgeon about which will be best for you.

The exact timing can be tricky. You should balance your personal life and obligations with when is optimal to give the cuff the best chance for healing. Typically, after the surgery, you will asked to not lift anything heavier than a cup of coffee for about 3 months although early passive range of motion and rehabilitation exercises will be incorporated.  As a result, most people need someone at home to help them with their activities of daily living, driving, and shopping.

The bottom line is that if you think you have torn your rotator cuff, immediately see a sports medicine physician or orthopaedist to determine if you have indeed torn your cuff and if non-operative rehabilitation or surgery is the best option for you.

Science is starting to focus on the determining the underlying causes of certain cancers and especially how metabolic problems like obesity and weight gain may potentially contribute.  While we know that obesity increases ones risk of colorectal cancer, kidney, esophagus, endometrial and breast cancer, there is new evidence from the University of Hawaii that shows middle age weight gain can confer an increased risk of prostate cancer in men.

Lead researcher Brenda Y. Hernandez, Ph.D., M.P.H., assistant professor at the Cancer Research Center of Hawaii studied a group of 83,879 men who were Hispanics, Japanese, white, Native American and blacks in a prospective study from 1993-1996.

Their data, recently analyzed suggests that excessive weight gain between younger and older adulthood increased the risk of advanced and high-grade prostate cancers in white men and increased the risk of localized and low-grade disease in black men, but decreased the risk of localized prostate cancer in Japanese men.

30 percent of prostate cancer cases occurred among Japanese men, 25 percent among white men, 27 percent among Hispanic men, 13 percent among black men, and 7 percent among Native Hawaiian men.

This difference in incidence of prostate cancer between men of different ethnic groups may be attributed to different proportions of fat to lean mass and where that fat is placed.

While it is difficult to jump to a conclusion that young adulthood weight gain causes prostate cancer, this study definitively shows that at the very least there is a strong correlation. Men at this age are undergoing much change after finishing school, entering new jobs, which may cause changes in eating habits, potential decreases in regular physical activity that results in weight gain.

I usually advise my college patients, especially those that are “retiring” from formal college athletics, that they have spent their lives forming poor eating habits that haven’t manifested in weight gain simply because they have been burning an extreme amount of calories doing sports. When they leave college, all of a sudden they aren’t burning as many calories, and metabolisms slow down yet they continue to eat similar quantities, so rapid weight gain ensues.

This new study is one more reason to encourage healthy eating habits BEFORE finishing college and some argue even before.

References:
1)    Cancer Epidemiology, Biomarkers & Prevention, September 1, 2009
2)    http://www.cancer.gov/cancertopics/factsheet/risk/obesity