December 30th, 2006 by Dr. Val Jones in True Stories
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Good medical diagnosis and treatment often requires some detective work. One of my patients came to see me for foot pain recently. She described what sounded like a pretty typical case of plantar fasciitis – pain in the heel of her foot, worst with the first few steps in the morning, improving throughout the day. I recommended stretches, physical therapy, night splints, ibuprofen… but to my surprise nothing was really helping.
One wintery day she came back on a return visit and I happened to notice her footwear – boots with a very thin, flexible sole. Slowly I began to think of her tromping over ice, sand, gravel, and snow in these boots… I asked her if she could feel the ground under her feet.
“Yes, I can feel everything – I don’t like to walk around in the snow and ice because it kind of hurts to step on all the lumps and bumps. But I can’t just stay indoors all day, I have errands to run!”
I explained to my patient that I had a hunch that the rocks were bruising her plantar fascia, causing it to be inflamed and painful. I asked her to buy herself some thick soled boots – the kind where she couldn’t feel the lumps and bumps under her feet.
About a week later my patient called to tell me that her foot pain was much better. The new boots seemed to be doing the trick… “I never knew why my plantar fasciitis got worse in the winter times, doc. I thought it was the cold that made things worse.”
Well, I had learned a lot too… sometimes the best treatment option is not on the standard protocol list. The power of observation is one of a physician’s most important weapons.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 29th, 2006 by Dr. Val Jones in News
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Well, I fell for it again – that panic that follows breaking news that a drug once thought to be safe was now causing some horrible, unexpected side effect. I nervously wrung my hands as I thought of all the proton pump inhibitors I had prescribed for heartburn in the past. Did I hurt my patients? Are they all lying in a hospital somewhere with pins in their broken hips?
I took a deep breath and decided to go back to the source of the news. There it was – the offending research study in the Journal of the American Medical Association. I read it carefully – looking for the devil in the details. And lo and behold, the caveats started slinking off the pages.
First of all, the “44% increased risk of hip fractures” sounds really bad, doesn’t it? Well, what if I said that a person’s risk of getting a hip fracture (IF they were over 55 years old AND took a proton pump inhibitor for over a year straight) was 1.44 in 1000 whereas if they never took the medicine, their risk would be 1 in 1000. Does that sound as bad? Well, I’m actually saying the same thing.
There were some other interesting details – men were significantly more likely to get fractures than women 1.78:1000 compared to 1.36:1000. There was no explanation as to why that might be. Also, I noticed that there was no discussion of a potential confounder – which of these patients were in nursing homes? In my experience, patients in nursing homes often automatically get proton pump inhibitors – and stay on them indefinitely as “GI prophylaxis.” Now if you’re sick enough or demented enough to be in a nursing home, then you’re probably at higher risk for falls… which would be a good reason why people on proton pump inhibitors break their hips more frequently, right? If you fall more frequently, then – bingo – there goes your increased risk for fractures.
Well, the research does seem to suggest that there’s a trend – people who take proton pump inhibitors for long times in higher doses may have a higher risk of fractures. But the jury’s still out on why that may be. For most folks in the US who are under the care of a watchful physician, their dose and duration of taking the medicine doesn’t put them at increased risk at all.
So to me the take home message is that people shouldn’t stay on proton pump inhibitors indefinitely, which isn’t really news to me. I hope that this blog entry has reduced your anxiety level… stay tuned for more critical analysis of research findings.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 28th, 2006 by Dr. Val Jones in True Stories
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Speaking from experience, back pain can be totally incapacitating. Several years ago I traveled to Colorado for my first ski trip in that beautiful state. As I was bending over to hoist my unimaginably heavy ski boot duffle bag over my shoulder, I suddenly felt a knife-like pain in my lower back. It took my breath away and I couldn’t stand up straight. My friends looked at me quizzically. I crawled into the ski lodge and lay on the floor, trying to understand what was going on. I assumed that the pain would pass in an hour or so… but three days later I still couldn’t really move. After some discussion with colleagues over the phone, I decided to call 911. My friend’s young kids were filled with glee as a firetruck pulled up to the lodge, and they brought in a stretcher to take me out. I felt like a total idiot – I hadn’t even hurt myself on the slopes. As a doctor I could imagine how eyes would roll in the ER when they heard: “32 year old female complaining of back pain after lifting her suitcase.” That doesn’t merit an ER visit, complete with firemen and ambulances, does it?
On my way to the hospital, tears filled my eyes with each jolt of the ambulance. I couldn’t control it, and I wondered if the ambulance team thought I was being a baby. I was stuffed inside an MRI machine soon after arriving in the ER, and the doctor who ordered it soon gave me the unexpected news: “everything looks just fine. Your MRI is normal.”
I couldn’t believe it. I was sure I had herniated a disk or ripped some muscles off my spine, or maybe I had burst a blood vessel in my spinal cord – or maybe I had cancer? Nope. Everything was normal.
I stayed overnight in the hospital – at one point I met the orthopedic surgeon on call. I could tell immediately that I was supremely uninteresting to him – nothing to operate on, give her some pain medicine and get her out of here! I just wanted someone to explain to me why everything was “normal” and yet each tiny movement made me whimper in pain.
Well, I wish I could tell you that I figured out the source of my pain, or that I found a miracle cure for it. As it turns out, it took about a month for me to move around comfortably again, nothing really helped the pain (vicodin made me sleepy and nauseated), and even now, from time to time I get a twinge of that old pain if I bend a certain way.
I guess what I learned is that pain is real – even if all the tests argue otherwise. And one thing’s for sure, I take all my patients’ pain complaints very seriously. “Throwing my back out” was the best education I could have had for my career in pain management.
Val Jones is a licensed practitioner of Rehabilitation Medicine and Senior Medical Director of Revolution Health’s portal. No information in this blog is intended to diagnose or treat any condition. The opinions expressed here are Val’s and do not necessarily reflect those of Revolution Health.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 28th, 2006 by Dr. Val Jones in Health Tips
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The plantar fascia is basically a thin, broad “rubber band” on the bottom of your foot. It holds your foot bones together and gives you a little spring in your step. But when that rubber band gets stiff, every step can be painful, especially the first few steps in the morning. So what would you do with a stiff rubber band that needs to fit around a deck of cards? You’d stretch it gently until it could fit around them, right? Well, as it turns out, that’s the best course of action for plantar fasciitis. There are many different ways to stretch the fascia (like rolling a tennis ball under the bottom of your foot) but my favorite method is: the night splint.
What’s a night splint? They’re little booties that keep your feet at a 90 degree angle when you’re lying down. This gentle stretching works while you sleep, so it couldn’t be easier. Night splints are available online or at most surgical supply stores, and cost upwards of $30. Try them for several nights in a row, and see if it makes a difference in the pain you’ve been feeling when you take your first steps of the day. Keep it up for a week or two, and you may have cured yourself.
Have you tried night splints? Still having pain? Find out what else might work in the next blog entry!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
