Dr. Nicholas Cappello

I was always of the opinion that there was too much ACLSurgery being performed. It boiled down to the QUICK FIX approach that Americans embrace. A Swedish study confirms my opinion. The Swedes make great studies because they have patients that they can follow-up for many years.Early surgery followed by rehabilitation for an anterior curiae ligament (ACL) tear is no more effective than skipping surgery and concentrating on rehab exercises, according to a Scandinavian study of young active adults.

Patients who did not have surgery reported the following:

1.  better levels of pain

2. ability to participate in sports and recreational activities and knee-related quality of life, compared to those who had early surgery

They article published in the July 22 issue of the New England Journal of Medicine, on patients’ responses to the Knee Injury and Osteoarthritis Score survey 2 years after tearing an ACL.

After 2 years, 61% of 59 patients who planned to forego surgery and concentrate on rehabilitation were able to avoid surgery and reported acceptable levels of pain, activity and quality of life. “More than half of the ACL reconstructions could be avoided without adversely affecting outcomes,” write the authors.

Whether a patient should have ACL reconstruction surgery sooner rather than later also may depend on type of activities the patient does, if you are a college soccer  or foot ballplayer .Then of course you need the repair but if you are a recreational athlete then give your body a chance to heal before going into surgery


The sideways growing portion of nail acts like a foreign body and pokes into or pinches off a small piece of skin at the outer edge of the toe. This may cause a break in the skin, causing inflammation and possibly infection. The inflammation often causes more thickening of the nail skin fold, further exacerbating the problem. The protruding piece of nail keeps pushing into the skin, causing further injury and pain

INGROWN TOENAIL CAUSES:

• Shoes that are too tight or too loose.
• Toenails that are trimmed too short.
• Toenails that are trimmed with the edges rounded.
• Having thick toenails or difficulty trimming them.
• Tearing a toenail rather than trimming it properly.
• Having very large toenails or naturally curved toenails.
• Injuring the toe, such as by stubbing

Treatment:

Helpful soaks options include:

1. dilute white vinegar (roughly 1 part household vinegar to 4 parts water)

2. Epsom salts

3. very dilute Clorox bleach footbath (approximately 1/3 teaspoon Clorox in one medium bucket of water or one capful of Clorox in one bathtub full of water)

EXECUTE THIS OPTION IN THE FOLLOWING ORDER BELOW:

• Elevate the foot and leg.
• Gently roll back the piece of overgrown skin after soaking the affected toenail.
• Gently slip a thin wisp of cotton or dental floss (tape) under the nail edge to help lift the nail off the skin.
• Trim toenails straight across (not too short), and avoid curving at the edges.

Whenever I have a patient with a broken bone I think of Osteoporosis.

Osteoporosis is a major public health threat, 55 percent of the people 50 years of age and older. In the U.S. today, 10 million individuals are estimated to already have the disease and almost 34 million more are estimated to have low bone mass, placing them at increased risk for osteoporosis. While osteoporosis is often thought of as an older person’s disease, it can strike at any age.

Osteoporosis is a disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. These broken bones, also known as fragility fractures, occur typically in the hip, spine, and wrist.

Osteoporosis has no symptoms. You notice no pain or change as the bone becomes thinner, although the risk of breaking a bone increases as the bone becomes less dense. A bone mineral density (BMD) test is usually done to see whether you have osteoporosis. The most accurate test of BMD is dual-energy X-ray absorptiometry (DEXA), although there are other methods. DEXA is a form of X-ray that can detect as little as 2% of bone loss per year. A standard X-ray is not useful in diagnosing osteoporosis because it is not sensitive enough to detect small amounts of bone loss or minor changes in bone density.

Many men don’t think they are at risk for osteoporosis, since these are commonly considered to be conditions of older women. Because men have a higher peak bone mineral density than women at middle age, osteoporosis tends to happen at an older age in men. But aside from the hormonal change in women as they go through menopause, the risk factors are risks for men as well as women. Men are also at risk if they have low levels of the hormone testosterone.

Your bones don’t reach their greatest density until you are about 30 years old, so for children and people younger than 30, anything that helps increase bone density will have long-term benefits. If you’re older than 30, it’s still not too late to make these lifestyle changes. A balanced diet and regular exercise will help slow the loss of bone density, delay osteopenia and osteoporosis, and delay or prevent osteoporosis.

1. Maximize calcium intake.
Most recommendations are for 1000 milligrams of calcium per day for both men and women.

2. Increase Vitamin D intake.
Once calcium is ingested, vitamin D is essential to help your body absorb it and utilize it. For both men and women, the recommended daily intake of vitamin D is between 400 and 800 international units. .

3. Exercise Regularly.
To improve and maintain bone density a combination of regular low impact, weight bearing exercise and resistance exercises works best. Weight bearing exercise includes walking, jogging and even dancing

4. Play Outside.
As little as 15 minutes a day of moderate sunlight is enough to provide enough vitamin D to meet the most people’s needs.

5. Avoid excessive alcohol.
Carbonated colas also promote absorption of calcium from bone. Excessive cola consumption should also be avoided.

6. Stop Smoking.
Smoking is toxic to your bones.

7 Medications.
Although there is no cure for osteoporosis, currently bisphosphonates (alendronate, ibandronate and risedronate), calcitonin, estrogens, parathyroid hormone and raloxifene are approved by FDA

I am still waiting for the Cause and Cure  for this painful condition and I hope we are getting close. Your Doc will call it Adhesive capsulitis, is an almost a complete limitation in shoulder motion in which active and passive range of motion are restricted. In the absence of a known shoulder disorder, the condition is referred to as idiopathic adhesive capsulitis…

There is a loss of shoulder joint volume and the shoulder joint lining synovium has marked changes. The characteristics and process have been well documented over the past half century but the optimal treatment remains vague

Although the cause of adhesive capsulitis remains largely unknown, it is likely the result of a few factors… Associated factors include female (women are affected more than twice as often as men), age > 40 years, prolonged immobilization, diabetes, trauma, thyroid disease, stroke, myocardial infarction, autoimmune disease, and prior adhesive capsulitis (20% to 30% of patients develop opposite-side adhesive capsulitis). The cause involves an inflammatory and fibrosing process, which is highly dependent on the stage of the disease.  The pathology of adhesive capsulitis includes a chronic inflammatory response with fibroblastic proliferation that may be auto immune in origin. My explanation to patients is the body thinks the shoulder joint belongs to someone else and is attempting  to prevent it from doing harm to it.

History and Physical Examination

As with most medical conditions, the key to diagnosis is a patient’s history and physical examination. Location and type of pain typically include a deep diffuse aching pain. Non specific sharp stabbing or burning pain may occur at the onset of motion. Night pain, like a deep, throbbing toothache-like pain, may wake the patient from sleep or cause difficulty starting to sleep. Onset of pain often precedes loss of motion. . Neck pain can result from the shoulder tiring to use other muscles and joints to compensate. Scapular dysfunction or compensation for glenohumeral stiffness. There are other conditions that resemble frozen shoulder…

Usually the easiest finding is loss of external rotation at the side, compared to the normal shoulder. Pain on touching the front of the shoulder is common. is I often will inject xylocaine and see if the joint will move to rule out the other conditions While Codman¹ described frozen shoulder as a benign, self-limiting process with all cases resolving within 2 years, further studies reveal that resolution can take significantly longer and that some patients continue to experience restricted motion and pain.

Nonoperative Treatment

Nonoperative treatment is most effective if initiated early in the course of adhesive capsulitis, before fibrosis begins. The mainstay includes a physical therapy program designed to decrease pain and improve range of motion. Therapy begins with passive stretch at end range of motion and should include a frequent home stretching program. Isometrics are allowed early, but strengthening should with withhold until full painless passive range of motion is achieved. Oral nonsteroidal anti-inflammatory medication and intra-particular steroids minimize inflammation and are useful for pain control…

Overall, patients are satisfied after a stretching-exercise program at 2-year follow-up. However, many patients still have some residual pain and motion limitation compared to their unaffected,  shoulder.

Operative Treatment

Operative treatment includes manipulation under anaesthesia +/- arthroscopic release. Open capsular release has lost favour because of an increased risk of loss of motion and. Surgeons can perform gentle manipulation followed by arthroscopy, or distention of the joint with saline followed by arthroscopy and then manipulation. Releasing the rotator interval first will have a profound effect on increasing the glenohumeral joint volume.

Conclusions

Non-operative management should be attempted as primary treatment in all patients and is successful in most. Surgical treatment is most effective after waiting  at least 6 months to a  year.   Advantages of an arthroscopic release are numerous: it allows for controlled capsular release; compared to a manipulation alone, manipulation after an arthroscopic release requires less force; a synovectomy and treatment of concomitant pathology can be performed; better results in diabetic patients than physical therapy alone;