JUST WHAT THE HELL IS A "SPRAIN?"

I really love reader questions. They are always better, and tougher, than the questions I pretend someone asked me and then try to answer in this blog. For example, nobody has asked me jack about the salmonella-tomato epidemic. Maybe people don't eat tomatoes anymore, or maybe the epidemic is not as serious as I think it is.

But people do get "sprains." I can guarantee you that you have either had a sprain at some point in your life, or you will someday. Sprains are common, but what are they?

READER QUESTION: IS A SPRAIN A REAL ENTITY, OR IS IT JUST A CATCH-ALL TERM DOCTORS USE TO SAY, "IT AIN'T BROKEN BUT WE DON'T KNOW WHAT THE F*CK IS WRONG WITH YOU"?

Answer: Really, a bit of both. The truth is that for most parts of the body, a "sprain" is actually a very vague, ill-defined, and broad term, at least when it's used by most doctors. I suppose it is meant to be reassuring to some extent, because when a doctor tells you that you have sprained something, he or she wants you to know that you probably have not "broken," "torn," or "dislocated" anything. That doesn't mean you're not in pain, and that you don't deserve a splint, a bottle of Vicodin, and some sympathy. But you're probably not going to get a cast all your friends can write on, two weeks off work, and THAT MUCH sympathy. Your friends are more likely to say "what's with the crutches bro? I thought you said it was just a sprain!"

The exception to the above is the ankle. An ankle sprain is actually a well-defined entity, generally broken down into degrees: a first degree sprain is mild, and a third degree sprain is severe. And if you've ever had a sprained ankle, you know this can be a serious injury. Clinically, a sprained ankle can be as bad-looking and painful as a fractured ankle, and the two are treated very similarly. In fact, a third degree ankle sprain often includes torn ligaments and can take even LONGER to heal than a fractured ankle. Both sprains and fractures of the ankle generally require a cast or immobilizing boot, with crutches and a lot of time off your feet. Depending on the degree of your sprain, an orthopedist or sports medicine doctor can tell you exactly which ligaments and tendons are stretched, swollen, or torn, and how long you will take to heal. Most primary care and ER doctors also take sprained ankles fairly seriously and know how to treat them.

I really think the term "sprain" is used loosely when it comes to other joints. I have had patients who were told they had a sprained arm, knee, wrist, neck, back, finger, hip, and even "pelvis." In these cases I suspect the doctor really didn't know what the hell was going on, but was trying to communicate the fact that nothing was broken. In these cases there is usually a more specific tendon, ligament, bone, or muscle that was bruised, hyperextended, or smashed. I try to be more specific in this regard, because some of these injuries will heal faster if a patient gets a splint, a course of physical therapy, or a medication.

SPRAINS: THE GOOD NEWS

-Most sprains get better eventually, even if the doctor who diagnosed you with a "sprain" doesn't really know what's wrong with you.

-Even if the pain from a sprain becomes chronic, there is a good chance it's due to an inflamed tendon (tendonitis), and it will still get better if you do some physical therapy.

-If you follow your doctor's instructions, even the worst sprain (a 3rd degree ankle sprain) can heal completely.

-If you have a sprain, the chances you will need surgery to fix it are minimal.

-If you are worried that your sprain is not going to get better and that something is permanently torn, you can always ask to see an orthopedic surgeon.

IS FASHION A HEALTH ISSUE?

    Some of my 2-3 readers may have noticed that occasionally in this blog, I make comments about fashion.   I have never been afraid to stray into controversy, which is why I can simultaneously say that "I care about fashion," and "people should wear Crocs."   Basically, I think that fashion has its time and place.   I think it's fun, and it's worth paying attention to: but not if it's destroying your health.   When I see patients with bunions, heel spurs, corns and calluses, and chronic foot pain, and they're wearing Jimmy Choo heels, I say: "I'm sorry, but you're going to have to quit fashion."   But when fashion is not causing you physical pain, I think it's both fun and at least somewhat important.   In fact, it may even be "healthy."

      Why is fashion, at least potentially, healthy?   Because, simply stated, it can make you feel good!   You see, health is not simply about avoiding illness and staying out of the hospital.  It's about feeling good, feeling alive, feeling "vital."   Some people absolutely don't need any sort of fashion to achieve this- but if you live in a city or any location in which you interact with lots of people, fashion might be a ticket to feeling a bit better about yourself.   It's also an opportunity to be creative and unique.   And contrary to what the New York big-name designers would like you to believe, fashion is neither an elitist nor an expensive endeavor: many of the most fashionable people cut their own hair, buy their clothes at Goodwill, and wear fake jewelry.     You see, fashion is like interior decorating: you can pay someone lots of money to do it for you, and it will probably look good, or you can be thrifty and creative, and make it look good yourself.   It's really up to you.

      So how do you bring fashion into your life?   Here's a hint: don't ask your doctor.   Most doctors know as much about fashion as winos know about sobriety.   Instead, just pay attention to people in your life who have a bit more "flair" in their clothing or hair.   Ask them for some tips.   Check out what people are wearing, or buying, in a hip thrift store.    Most of all, don't be shy- and certainly, don't be cautious.   Try wearing something that you would never dream of wearing.    And if all else fails: ask a gay guy to give you some fashion advice.  I have no idea why, but gay men often have a unique eye for good clothing and good makeup (provided that they are not gay men from Denver!)

      I know, fashion may not be at the top of your list of things that you want your doctor to talk about.    But I'm not your doctor.   I'm Doctor Tofuhead, and I don't want you to simply feel good.  I want you to look good.  

PATHETIC: YOU CAN'T EVEN COUNT ON TOMATOES, OR THE LAKERS AT HOME

Wow. I just watched perhaps the biggest blown lead in a sports game ever. Yes, I mean the Lakers losing to the Celtics at home. I will still refrain from making any NBA finals predictions, given my record of being wrong about this subject 99% of the time (which is just 1% less than Jeff Van Gundy!)

On to subjects I do know about:

THE SCOURGE OF TAINTED TOMATOES

You may have heard about the massive salmonella outbreak sweeping the West these days, the source being tomatoes. I had to laugh when I saw the FDA's official recommendation that consumers avoid "Roma tomatoes, round tomatoes, and plum tomatoes, but other tomatoes are considered safe." Hmmm- exactly which damn tomatoes are safe? Given that all tomatoes other than Roma tomatoes are generally "round," what the hell was the FDA thinking? I think they should have clarified the issue by simply stating: "If consumers can find tomatoes which are square, pyramidal, or shaped like a donut, they should eat those tomatoes, which do not occur in nature but can generally be regarded as safe."

But never fear: despite the FDA's incompetence, there are tomatoes that are safe to eat these days. They are:

1. Tomatoes you grow yourself.

2. "Cherry tomatoes"- yes, they are round, but round doesn't count if they are also "very little." But watch out for plum tomatoes, which are also round but just "kinda little!"

3. Tomatoes with the vine still attached. These are a great find, because for some reason they are cheaper than most other tomatoes this summer. There must have been a bumper crop. They are also juicy and delicious, and are great salad tomatoes and decent saucing tomatoes.

QUESTION: WHY DO TOMATOES HAVE SALMONELLA?

Answer: somehow, it's come from a contaminated water source. That's part of why tomatoes with the vine attached are safe- the part of the tomato where the vine was attached is porous, unlike the rest of the tomato, which is actually relatively impermeable to water. It likely has nothing to do with chicken or eggs, which we commonly associate with salmonella. How the water got contaminated, or why it has affected so many tomato producers, is still a mystery at this point (according to the FDA).

QUESTION 2: WHAT IF I GET SALMONELLA?

Answer: don't worry too much, you probably won't die. In fact, as of this morning only one person has died from salmonella-tainted tomatoes this year, and that person was already very ill. Salmonella generally will give you a ferocious case of diarrhea, with relatively frightening bloody, mucus-filled bowel movements. You will also have a fever, chills, muscle aches, and you will feel like crap. But even if you get no treatment whatsoever, your salmonella infection will almost certainly go away on its own in a week or less, and if you get an antibiotic from your doctor you'll get better a bit sooner. Still, it's probably not a great idea to skip out on your doctor if you have bloody diarrhea. If you've eaten a questionable tomato and you're feeling ill, make an appointment!

QUESTION 3: ARE ORGANIC TOMATOES SAFER?

Answer: I'm not sure. The best I can say is "probably." There is just not enough info yet on where exactly these tainted tomatoes are coming from. But given the wide spread of the epidemic, I would GUESS that the salmonella is affecting one or more large producers, and organic tomatoes usually come from small producers. So if you really want to eat a Roma or a plum tomato, I'd recommend it be an organic one, or one you grow yourself.

LATER THIS WEEK: WHAT EXACTLY IS A "SPRAIN?"

HOME COURT ADVANTAGE: YOUR KITCHEN

    Before I start on today's tirade, let me clarify my post about vitamins, because I forgot to mention 

PRENATAL VITAMINS: TAKE THEM

    While good evidence for the use of multivitamins is scant, evidence of the benefits of PRENATAL vitamins is not.   If you are pregnant or trying to get pregnant, you definitely should take a prenatal vitamin daily.    Why?   Because there are 2 things that pregnant women often don't have, or get, enough of (besides sleep): Iron and folic acid.    The placenta of a developing child is an incredibly hungry organ, and to keep it growing and providing oxygen to your baby, you need to be taking quite a bit of iron.   Many women are at an iron disadvantage already- this is simply because whenever you lose blood, you lose iron, and women of childbearing age lose substantial iron with menstruation every month.   It's surprisingly easy to become iron-deficient as a woman; all you have to do is have your periods and not eat steak that often!   Prenatal vitamins help make up for this by having a small amount of iron, since a small amount is all you can absorb from a supplement anyway.   Even if you eat red meat regularly, it's almost impossible to get too much iron when you're pregnant, so I recommend taking a prenatal vitamin no matter what you eat.

     AND, folic acid is probably even MORE important when you are pregnant.   Somehow, this vitamin is critical to the complete development of the nervous system, and even a slight deficiency in folic acid during pregnancy can lead to "neural tube defects."   These are birth defects in which the spinal cord, which starts as a hollow tube that closes off into more of a solid "rope," doesn't fully close at one end or the other.  Babies with neural tube defects usually survive and turn out healthy, but they often have to undergo a complex surgery to repair the defect.   Prenatal vitamins have the full amount of folic acid you need in a day, and they have made a HUGE impact in reducing the frequency of neural tube defects.

IN SUMMARY:  The benefits of prenatal vitamins are clear, and unlike multivitamins, prenatal vitamins have a ton of science and experience to support their use.   And since you can't always predict when you are going to get pregnant, my recommendation is this: if you are even remotely THINKING about getting pregnant, pick up a prenatal vitamin.   They are generally just labelled "Prenatal Vitamin" and they are cheap, and well worth the small cost!

TODAY'S TIRADE: ANNOYING THINGS OF THE WEEK

    I try to be nice most of the time, especially on this blog.   But as my wife and friends well know, sometimes I go off the deep end into relentless tirade about various and sundry topics.  So I just have to vent a bit, by just mentioning a few things I've been thinking about. 

     Here are my top 10 most annoying things of the week, if not the whole summer:

1. MasterCard commercials

2. People arguing that Hillary Clinton should be Obama's pick for VP

3. John McCain's fake smile

4. Competitive cooking shows

5. People bitching about gas prices

6. Wearing flip-flops with pants

7. The NBA on ABC, but only because of Jeff Van Gundy and how much he sucks

8. Having to see everyone's shitty tattoos all summer

9. Vitamin Water

10. Coors referring to itself as "The Banquet Beer"

Most of these are obviously annoying to anyone with common sense.   Let me quickly justify a couple of these, however.  For example, let's talk about "flip flops with pants."  First of all, a flip-flop is not a shoe, or even a sandal.   It's basically like a shower cap, a hair curler, a spandex bikini, or a bathrobe.   If you're going to wear it out of the house, just throw in the towel and wear shorts and a tank-top so that we know you'd basically be walking around nude if it was legal.  When you wear actual pants or a long-sleeve shirt with flip-flops, it just looks like someone stole your shoes.   It also calls attention to your feet, which no one really wants to see unless you have pretty feet.  Men, this rules you out.   I'm sick of seeing your pasty, hairy feet so go get a pair of Vans or something.   If you wear flip-flops with shorts or a skirt, at least the attention gets called to your legs, which have less of a chance of being hideous.

    Now a word from MasterCard.    Tonight's MasterCard commercial during the NBA finals game literally said: "Burger and Fries: 4 dollars.   Making every minute count: Priceless."  It showed some office guy in a tie wolfing down a burger next to a computer.   It made me want to puke.   Why?   Because "making every minute count" in this case meant losing as little work time as possible, even at the expense of health.    It implied that if you eat crappy and quickly so that you can get back to work quickly, you've done yourself a favor.   Actually, you've only done your employer a favor, because for you, the opposite is true: making those few minutes count might actually be shaving hours, days, weeks, or years off your own lifespan.    So do yourself a favor- don't use your MasterCard to get a crappy lunch so that you can contribute to your employer's bottom line.   Do what Dr. Tofohead does- lock up your office and eat a healthy, homemade lunch, so that you can make every minute of your RETIREMENT count.

     I can't resist a quick word about that intolerable beverage "Vitamin Water."  First of all, it should be called "high fructose corn syrup water," because that is primarily what it is.  In addition to a massive jolt of simple, non-nutritious sugar, Vitamin Water has a small amount of vitamins, but much less than a generic multivitamin tablet.    And on a per-serving basis, the vitamins in "Vitamin Water" cost TWENTY times as much as the vitamins in a Centrum 1-a-day vitamin.   So stick to water, and if that's too plain for you, have a shot of high-fructose corn syrup to wash down your multivitamin.

     The tirade is over!

   

WARTS: AN INTRODUCTION

Did you know that there are only 2 kinds of warts? This is a good thing, because it makes self-diagnosis and treatment of warts quite simple. You can treat your own warts at home, but you should not be shy about going to your doctor to have warts treated. You see, doctors like warts. Warts give a doctor an opportunity to cut, shave, and freeze- satisfying procedures that make us feel like we're "doing something." I always get excited when a patient is coming in to have some warts treated, because I know it's going to be fun.
THE TWO KINDS OF WARTS:

1. Genital warts: these are caused by a strain of the human papilloma virus, or HPV. They generally occur in the genital area, but can occur on the anus as well. While they don't always cause cancer, they do have the ability to transform skin cells into cancer cells in some cases. For that reason, it's not a great idea to leave genital warts around, hoping that they will go away. It's also pretty hard to treat these at home; over-the-counter wart medications don't usually work on genital warts, and most of them will require a prescription cream or some freezing.

2. Common warts: these are the raised, rough warts that occur on the hands, elbows, and the feet, usually on the bottoms of the feet. These warts are also caused by a virus, in this case a strain of virus called human herpes virus 8, or HHV. The terminology is confusing because HHV is not a true herpes virus, and it does not cause herpes. It just causes these benign, painless, but annoying warts on hands and feet. Unlike genital warts, common warts do not ever cause cancer and they can be treated at home.

HOW DO WARTS SPREAD?
1. Genital warts: unfortunately, genital warts are very contagious. Brief skin contact with a genital wart can transmit the HPV virus from person to person. What's worse is that skin and mucus membrane contact with someone who has HPV can transmit genital warts EVEN IF the infected person does not have any warts, and EVEN IF they have never had any manifestations of HPV. For this reason, genital warts are scary, and they are common. Only condoms can prevent you from getting genital warts.
2. Common warts: the amazing truth is that we don't really know how common warts on the hands and feet are spread from person to person. You can touch someone's hand wart every day for years, and you probably won't get a wart. There are theories, none of them remotely proven, that the HHV virus that causes common warts lives in soil, bathroom floors, etc- but the truth is that we don't know. If you have a common wart, and chances are that you will sometime in your life, we just don't know where it came from.
HOW WARTS ARE TREATED: GENITAL WARTS
Most commonly, genital warts are given a freezing treatment with liquid nitrogen in your doctor's office. There is a cream called Aldara that has revolutionized genital wart treatment- this is applied at home and can completely eliminate warts, though it does cause skin irrititation. You need a prescription for this from your doctor. In my office, I usually freeze genital warts first, then have my patients use Aldara at home; in combination, the 2 treatments can eliminate the vast majority of genital warts. There are other topical medications that your doctor can prescribe as well. If all else fails, dermatologists can remove the most stubborn genital warts surgically or with laser treatment.
HOW WARTS ARE TREATED: COMMON WARTS
Freezing works great for common warts, but there are effective treatments you can use at home. You may have heard of patients treating warts by covering them with duct tape- this may work, but only about 30% of the time. Duct tape is actually a pretty crappy wart treatment when used alone. But salicylic acid is a great treatment, and it's available in drug stores without a prescription. As a liquid it is sold as "Compound W" which is dropped on the wart; it also comes in little patches, most notably Mediplast (by Dr. Scholl's). For home treatment I recommed that patients apply a Mediplast patch over warts, then cover the patch with duct tape. Any time the patch and tape falls off, it needs to be replaced with a fresh patch. This is important because it takes about 2 weeks of continuous coverage with salicylic acid to remove a wart. I'm not sure the duct tape does much, but it does help keep the salicylic acid patch in place. Using this method, all but the largest warts will usually completely fall off in 2 weeks.
You can also speed up the removal of a wart by filing down the dead skin. Periodically take a nail file or pumice stone, and rub off the top part of the wart. Don't do this if the wart starts bleeding.
Finally, some new products available in drug stores allow you to freeze your own warts. These products are not as cold as the liquid nitrogen doctors use, but they still can work. If you use one of these sprays or applicators, make sure to freeze the wart until it's completely white, then allow it to thaw out, and freeze it again 2-3 times. If it does not hurt at least a bit, you are probably not freezing the wart enough. The skin under the wart may blister after freezing- if so, leave it alone. Eventually it should dry out and the wart should fall off.
If home treatment does not work, you should see your doctor. Your doctor may cut some of the dead tissue off the top of the wart (this is painless), then freeze the wart underneath. For large warts, it can take 3-4 treatments (usually once a month) to finally get rid of a wart. But all warts can be conquered eventually!

THE SIMPLE TRUTH ABOUT VITAMINS

    "Should I take any vitamins?"   That's a question I get all the time in clinic.   Not that patients listen to me; many have a laundry list of vitamins they take, regardless of what I tell them.   I just can't seem to get people to stop taking vitamins- perhaps because people think they are "natural," which they are not, they must be good for you.   In fact, ALL vitamins you buy in the store are synthesized in a chemistry laboratory.   There is nothing the least bit natural about them.

     The worst thing about vitamins is that, for the most part, they don't work.   Enormous studies have tried, optimistically, to find some health benefit of supplemental B vitamins, vitamin C, vitamin A, and vitamin E; to no avail.    In fact, vitamin A seems to increase cancer risk, though only very slightly.   These other vitamins, when taken as a supplement, probably do little or nothing.

     Are there any vitamins worth taking?   I'd have to say yes, in some circumstances.   Vitamin D is looking pretty good these days, for a number of reasons:

1. As our awareness of skin cancer grows, our exposure to sun goes down, and sun produces vitamin D in the skin, a major source for humans.   As a result, vitamin D deficiency is extremely common.

2. Vitamin D is essential for calcium absorption, and therefore to bone health.   To maintain strong bones, you need vitamin D as much as you need calcium.

3. Studies have shown that vitamin D seems to have properties essential to the nervous system as well.   Seniors, for example, had better balance and fewer falls when they took vitamin D in a recent study.

WHAT ABOUT MULTIVITAMINS?

      "Multivitamins" are usually "multivitamin/multimineral supplements." That is to say, they have most essential vitamins in them AND most of the essential minerals in various amounts.   There is little scientific evidence that multivitamins have a major benefit on health.   This is probably because a reasonably balanced diet has all the vitamins and minerals we need, in appropriate amounts.  However, unlike individual vitamin supplements which usually have huge quantities of a single vitamin, most "one-a-day" multivitamins have a modest amount of all the main vitamins.   For this reason, I have less of a problem with these- overall, my opinion is that a daily multivitamin can't hurt.   I take one myself (regular Centrum one-a-day).   I know it contains a modest amount of a good vitamin, namely vitamin D.   It also has a few minerals I might not get enough of, such as iron, calcium, and zinc.   As for the rest, I probably don't need it- but at least nothing is present in large amounts.

VITAMINS: SUMMARY

1. Take a multivitamin once a day if you want to and can afford to; but if your diet is fairly diverse, you probably don't need it.   If your diet sucks, and especially if you don't eat lots of vegetables, you might actually benefit from taking a multivitamin.

2. Don't spend a ton of money on a multivitamin.   Good old Centrum, and drug-store generic equivalents of Centrum, have an excellent and broad formulation of all essential vitamins and minerals, coming from a reputable lab.   Health-food-store multivitamins are more expensive and of questionable quality in some cases.

3. If you are thin, elderly, don't eat dairy products, or have ever had a fracture, you might want to take a mixed calcium/vitamin D supplement.   This is often NOT a good idea if you have had kidney stones.    A total daily dose of 1200 mg of calcium and 800 IU of vitamin D is a good bet, but talk to your doctor if you're a senior citizen- you might benefit from a higher or lower dose. Overall, few vitamins or minerals have the proven benefits of calcium and vitamin D!

4. Keep your diet varied and variable.   The more different things you eat, the more you are offering your body all the vitamins and minerals it needs, in a variety of forms.   No tablet is ever going to do for you what a good diet can.  

THE NUMBERS DON'T LIE: THE FRENCH ARE HEALTHIER

    Well, I finally got some hard data and the truth hurts: despite smoking more, drinking more alcohol, and eating fattier food than Americans, the French actually do live longer than we do.   Life expectancy in France is a full 3 years more than it is in America.  That may not sound like much, but when you look at the full spectrum of countries, it turns out that France has a longer life expectancy than the vast majority of European countries; moreover, the U.S. has a shorter life expectancy than ANY European country, with the exception of Ireland and Denmark.  Even (gasp) Bosnians live longer than Americans do.  So rather than asking, "why do the French live longer than we do?" you might ask "why do Europeans live longer than we do?"

      I have no frickin idea, to tell you the truth.   I have only been to the Netherlands, Ireland, England, Greece, and now France.   I can understand why Greeks live longer than we do- I have never seen so much salad and fresh seafood consumed as I did when I hung out in Greece.   Moreover, Greeks seemed to be chronically happy and relaxed most of the time.   But the French are an enigma.   They seem to suck down cigarettes the way Greeks suck down salad.   They eat meat in more varieties than I thought possible.  They seem to start consuming alcohol with gusto around noon.   Is it the carbs?   No.  Consuming a baguette a day (made with white, processed flour) is the norm among the French, and that's after they have enjoyed croissants and various pastries all morning.  

       So why, in fact, do French people live longer than Americans?  Here are my leading theories:

1. The French are not as fat as Americans.   

2. They walk more.   At least in Paris, if you can't walk well you are fairly hosed, because driving a car is supremely difficult and parking a car is impossible.

3. They work less.   This assumes, of course, that work is not healthy, which I'm not sure has really been proven.  But French people seem to take very long lunches and go home early.  Sounds at least mentally healthy.

4. French people clearly eat more fruit than Americans.   Fruit is everywhere.   The crappiest theatre or museum snack bar or coffee-cart in France sells little fruit salads, and all over Paris people are eating their fruit.   I can't remember the last time I saw an American pay to eat fruit in a restaurant.   

5. Flies must carry some essential nutrient.   I say this because in Paris, much food is sold in open-air markets and all the food has flies landing on it.  In all seriousness, the cheese shops all have open doors and the cheese has flies just relaxing on it.     In fact, the more expensive the cheese in Paris, the more flies there are walking around on that cheese.   It would be impossible to get a good piece of meat, fish, or cheese in Paris without flies being on it at the time of purchase.   One can only conclude that flies somehow improve the quality, or health value, of the food in France.

      Obviously, none of these theories are very satisfactory.   If you have your own theory, feel free to let me know.   In the meantime, I'm going to start eating moldier cheese and trying to encourage more flies to land on in.