The Pot Belly - a sign of prosperity ..... think again!

It's customary in India to see a man with a pot belly/paunch and say "it's a sign of prosperity". The origins of this comment are deep routed. Weight loss is associated with illness. Weight gain is associated with newly acquired wealth and hence access to richer foods. In addition a typical Indian mother is obsessed with feeding her children. A rolly-polly child seems to bring immense satisfaction to his/her mother. She feels she is doing her job well. This obsession continues even when the children become adults. If an adult male loses weight it is assumed that his wife/mother is not looking after him. To his/her friends and family, a person's pot belly is accepted easily. It's hardly a matter of concern! It's to be joked about and forgotten. 

The truth couldn't be further from this. The pot belly is the root cause of all health issues today. It's literally a house of disease. It will bring in its wake horrendous illness' like blood pressure, diabetes and the dreaded coronary heart disease (heart attack).  It is a measure of a persons lack of physical fitness. People with pot bellies are more prone to back pain (lumbar spondylitis) and knee pain (osteoarthritis). It is also a direct indicator of a persons unhealthy eating habits. 

Pot bellies were not so common until recently. Why didn't our ancestors have a pot belly? What are we doing wrong? Our fore-fathers did a lot of physical activity. No access to vehicles meant they were walking a lot. No elevator meant they were climbing stairs. They were lifting their own bags. They were using cycles and not motor-cycles. They had to walk to the market to buy their vegetables, walk to pay their bills and walk to the bank. With the progress in technology, mobile phones and internet, we are doing everything from the comfort of our home or office. The result is a near complete lack of physical activity. That is not all. There is a change in diet patterns. Our fore-fathers ate natural and home made food. Going to a hotel to eat food was not even a monthly event let alone every week or every day. There were no fancy bakery products like cakes, biscuits, toasts, etc etc. There was no packaged food industry and therefore no (or less) chocolates, sweets, ice creams, colas, chips, chevda, mad angles, etc etc. As a result, people in those days did hard physical work and ate healthy food. So it comes as no surprise that in today's day and age, the pot belly is common and so are lifestyle illness' like diabetes etc. 

The new age brought with it a food evolution. Sugar became the new mantra. Adding sugar made food tasty and easier to sell. As a result packaged food items associated with with wealth like chocolates and colas were packed with sugar. In fact most packaged food items contain sugar. May it be a seemingly harmless biscuit or apparently healthy cornflakes. This kind of sugar is hidden and we don't know about it till we read the ingredients. Only recently research has shown a direct correlation with sugar intake and obesity. 

Now it becomes clear ..... A paunch is truly a sign of prosperity as only the wealthy can indulge in these expensive packaged sugar products. And the whole food and advertising industry wants you to spend money on these food stuffs. The newspaper is full of the adverts and so is the television. Gullible people like us are falling prey. They are doing exactly what the adverts tell them to do. Biscuits, jams, chocolates have become part of our lifestyle. We cannot imagine a world without them. 

We need to wake up and realise how foolish we have been. We need to go back to the ways of our ancestors. We need to say no to the cola and yes to a walk. We need to look down on our pot belly and get rid of it immediately. We need to caution our friends and relatives and inspire them to get rid of theirs. A pot belly is a recipe for disaster and no trivial joking matter. 

It is now time for a paradigm shift. Exercise must not be seen as an optional leisure activity that you do if you have spare time. It's a necessary task of daily routine like eating a meal or having a bath. Similarly food must not be viewed as ‘going on a diet to lose weight’ but a healthy, natural (low sugar, low oil) eating habit must be developed as a permanent lifestyle change. 

PAINLESS - Total Knee Replacement

Total knee replacement is a highly successful surgery. Patients disabled with knee pain who can barely walk on their deformed legs undergone a dramatic transformation after the surgery. They experience complete relief from pain and complete correction of deformity. After surgery they don't need pain killers. They can walk normally without a stick or walker and at a normal pace. 

However the surgery is a major procedure involving cutting of muscle and bone. This leads to a slow and painful recovery. Post surgery pain after knee replacement can be unbearable and remains as a major deterrent to someone who wants to undergo the operation. Traditional methods of pain control include intravenous or intramuscular analgesic injections and epidural pumps. Intravenous medicines have safety issues and are not effective. Epidural pumps involve placing an epidural catheter (a very thin tube) in the epidural space near the spinal cord. Through this tube medicine is administered which numbs the spinal nerves and relieves pain. A well functioning epidural pump is very effective but has certain problems. Firstly, placing an epidural catheter is a blind procedure and many times the catheter is not in an ideal position. As a result it fails to reduce pain. Secondly, epidural pumps may cause a drop in blood pressure in some patients which requires constant monitoring. Lastly, epidural medicines may cause temporary sensory loss and motor weakness in the legs which makes walking after surgery difficult. 

In recent years, technological advancements in the science of anaesthesia and pain management have made painless knee replacement possible. Patients are standing and walking by evening on the day of surgery! Nerve blocks are a known technique of analgesia (pain relief). Two technologies have become available to the anaesthetist in the operation theatre which have revolutionized the efficacy of nerve blocks. First is a nerve locator. As its name suggests it helps in precisely locating a peripheral nerve which then can be blocked by administrating medicine. Second is portable ultrasound. Combining these technologies increases the accuracy of locating a nerve to 95%. This allows the anaesthetist to confidently block peripheral nerves (nerves outside the spinal cord) with predictable success. In the case of knee replacement, a femoral block and an adductor canal block is used to numb the pain. These blocks are effective and safe. There is no drop in blood pressure and no motor weakness. As a result we have successfully eliminated the need for epidural pumps. 

Another advance that we routinely use is called LIA - Local Infiltration Analgesia. This involves injecting a combination of medicines in the local tissues around the knee joint at the end of the surgery. With modern drugs and optimal doses, this technique alone numbs the knee for 12 to 24 hours. Again the technique is safe and effective. it does not require monitoring of blood pressure and does not cause any weakness. 

The last addition is that of pain patches. Newer opioid analgesics (artificial morphine substitutes) are available as pain patches. A single patch can work for a week. The action is not only long lasting but fast as the medicine is directly absorbed in the blood from the skin (bypassing the stomach). 

Not only is total knee replacement a highly successful surgery, it is now a comfortable and pleasant experience as well. Today’s analgesia is safe and effective. All patients are able to walk on the day after surgery and many manage to walk on the same day. Nerve blocks, LIA and Pain Patches are so effective that they have made painless knee replacement a reality today.

Self Preservation

How often have we seen a personal crisis ruining life? A young man just managing to settle down in life suffers a heart attack! He now faces a prolonged recovery and loses his job. Medical expenses coupled with a loss of income push him into a financial crisis. A young woman juggling her job and family life suffers an accident. A slow recovery means she cannot look after her children. All of us dread a personal crisis but what do we do to prevent it? We must think about self preservation. We must take precautions to avert a potential crisis!


An accident is top on the list. Accidents can occur in a variety of places. They can occur on the road, at home, at work or when travelling. The most common and the most dreaded are road accidents. The road conditions in many developing countries are pathetic and accidents occur rampantly. Yet I see few people thinking about prevention. Wearing a helmet is a simple basic precaution which will save a person from a potentially lethal or paralysing head injury. It is the difference between getting up and walking away from an accident versus an injury which may  lead to permanent disability and handicap if not death. The same applies to wearing a seat belt in a car. Seemingly simple, easy and effective precautions and yet many of us don't do it! Why? Because we don't think about life preservation untill it's too late. Following road rules (like using an indicator or not cutting lanes), avoiding rash driving and speeding, stopping at signals, keeping the vehicle well maintained and regularly serviced go a long way in accident prevention. Talking on the phone while riding a bike or driving a car is another recipe for a catastrophe! What about accidents at home? In the kitchen, be careful with the cooking gas! Old malfunctioning pressure cookers can burst, hurriedly used sharp knives can cut fingers and hot utensils and boiling oil/water can burn. The other danger zone at home is the bathroom. Make sure the bathroom floor is non slippery. There should be support handles for old people to get up. Beware of sharp shelf edges which could injure if one falls.  Don't climb on a chair to reach for a high shelf or clean the fan, use a stable ladder. The same rules apply for the work place or when travelling. We must be extra careful when travelling. An accident in a foreign land can be particularly nasty as we are helpless and often end up with less than ideal medical care.


The next is a medical crisis. We cannot control all the factors that lead to illness! But we can definitely control some of them. Young people get so busy with work and family that they don't have time for health preservation. The modern motto is to work hard now and enjoy the fruits after retirement. But reality is quite the opposite. By the time they retire,  people are bogged down with so many medical problems that their old age is nothing more than suffering, pain, doctors visits and a long list of medicines. Little does one realise that the efforts to achieve a healthy old age need to start when one is young. The idea of an investment which will pay returns in the future appeals to all but they are unable to apply the same logic to health. And yet, the truth is that investing in health remains the most profitable proposition. What factors can one control? Most critical is to stay away from addicting substances like cigarettes, alcohol, tobacco and drugs. These substances guarantee a life of suffering and a miserable old age. Beyond that, a healthy lifestyle boils down to two main factors - diet and exercise. I have written a number of articles on diet and exercise. Interested readers can access them on my blog - www.orthindia.blogspot.com. A good diet is about good quality foodstuffs and portion control. We must educate ourselves about which food is good for us. We ought to consume more protein and fibre (vegetables and fruits) and less carbohydrates and fats. We need to differentiate between good carbohydrates (chapati) versus not so good carbohydrates (rice) versus bad carbohydrates (potato, bread, maida, cake, jam, biscuits, cold drinks, sugar, mithai, ice cream, bakery products, chocolates and sweets). Stay away from bad carbohydrates. They are poor quality foodstuff. Portion control remains the key to weight reduction. Amount of food to be consumed in each meal should be decided before we start to eat. Eat only small amounts of food for lunch and dinner and compensate by having healthy snacks in between. A heavy meal neutralises the benefit achieved from a long period of starvation or a session of exercise. We must eat slowly to feel satiety with seemingly small quantities of food. Make it a habit to read the ingredients label on food packets to look for hidden sugar. As a thumb rule, food cooked at home will always be healthier than eating out. Be careful when eating outdoors or when travelling as chances of ending up with an upset tummy and loose motions are high. For exercise, do activities that you enjoy! There are no set rules. Choices are plenty from walking, running, cycling, swimming, aerobics, going to the gym or doing yoga. Remember that the only bad workout is the one that didn't happen. Aim to do some exercise for at least half hour, 5 times a week. Ideally one needs to exercise for an hour every day. Today people lead stressful lives, eat poorly, avoid exercise and buy medical insurance. The smart choice would be to work towards health and not ever need insurance.
The last aspect of illness prevention is timely screening for silent diseases and treatment of medical problems. Problems like blood pressure, diabetes and heart disease may not result in any symptoms for many years. An early diagnosis is crucial for preventing permanent damage. So everyone must get themselves screened for these illness' on a regular basis. It does not end with screening. One needs to to take proper treatment of his/her illness. For hypertensive patients, blood pressure should be controlled. For diabetes, blood sugars should be controlled. A diabetic patient must own a home blood sugar testing machine and must check blood sugars every week. Timely and regular intake of medicine coupled with regular testing and doctor's follow up is essential. 


A mention must be made here about the weekend warrior. These are the people who indulge in contact sports like football only on the weekends. Such sports require a high level of physical fitness which can come only with vigorous daily exercise. Those who don't exercise have weak muscles which offer poor protection to the joints. Hence the weekend warrior is much more prone to injury to the shoulder, wrist, knee or ankle than the physically fit person. Those who don't exercise daily are better off avoiding weekend sports.


Self preservation is an awareness that must be cultivated in the mind. A constant vigil will reduce the chances of a potential tragedy. Simply put it is the difference between happiness and suffering. The choice is really ours to make. Is it worth riding a bike for thrills or spending all your time at work or gorging on meals till your shirt buttons pop? We ought to rely on ourselves to look after our health rather than medical insurance ...... prevention will always remain better than cure!!

The Secrets to losing weight…

Many want to lose weight and many need to. Many try but few succeed. What is the secret of their success? Is there one secret or are there many? Do doctors know all the answers? Maybe, but aren't there lots of obese doctors around? 

In my practice I have had the opportunity to speak to both types of people; the ones who have lost weight and the ones who have failed. I myself have struggled for many years to lose weight only to find success recently. So what are these secrets? 

Secret 1: Sincerity. People who successfully lose weight have a deep commitment and sincerity in their effort. It is akin to a project that they have taken up and need to see it to completion. They work hard to lose weight, they have pride in their effort and they celebrate their achievements. Quite often the commitment comes due to a life altering mishap that they have suffered like a heart attack or a complication from diabetes. It is only after a major near death experience do they realise how fragile life is and how much they have taken for granted. I urge readers to take weight loss seriously and not wait for their wake up call!

Secret 2: Exercise or Diet? Is dieting enough to lose weight? or is exercising enough? or do we need both? the reality is that diet is far more crucial to reduce weight than exercise. Exercise helps but diet is the key. Those who exercise but continue their usual eating habits almost never lose weight. Of the weight one loses, 75% will be due to changes in diet and 25% will be due to exercise. 

Secret 3: Quality of food. Is it acceptable to buy petrol mixed with water? We are so particular about quality of the things we buy, however we stop thinking of quality when it comes to food. We are ruled by taste. What tastes good is good. Its time to stop and think about what we consume. We ought to eat only quality food. We should avoid deep fried foodstuff. We should also avoid artificial sugar. Avoiding sugar doesn't stop at adding Splenda to tea. One cannot imagine the extent to which artificial sugar has infiltrated our eating habits! Biscuits, chips, packaged snacks, cakes, chocolates, sweets, mithai, cold drinks, ice creams etc etc are all loaded withartificial sugar. This modern sugar stresses the body's mechanisms to control blood sugar. The body converts all this excess sugar to fat and stores it, resulting in a pot belly. The hotel industry, the biscuit manufacturer, the bakery, the chocolate industry, the Paani-Puri Wala or the Wada-Pav Center are not interested in your health. They thrive on our weakness for taste. So when I say avoid fried foods and artificial sugar, I really mean one must avoid eating packaged food (what is typically stocked at a Kiraana store) and one must avoid eating outdoors. Home cooked meals will always have the quality you are looking for! In addition to this we must reduce our consumption of the GREAT FOUR! They arerice, potatoes, pasta (and other maida products) and bread (bakery products). These products are similar to sugar and have high carbohydrate content which will be converted to fat. Once one learns to avoid these poor quality foods, what remains is all healthy. Wheat (or jowar, bajra) chapatis, dals, vegetables, meat (in limited quantity)  and nuts are healthy to eat. To this we can add cereals(without sugar), muesli, oats, milk and eggs. Milk products without sugar like dahi and chaas are good. The sugar in fruit is natural and far far superior to artificial sugar. One can safely consume all types of fruits unless diabetic. Raw vegetable salads (without unhealthy mayonnaise dressings) are a complete winner. Now with this knowledge lets assess the quality of some of our foodstuffs - first the seemingly harmless 'wada-pav'. It has got potato, maida and bread. Plus it is deep fried. Its a total disaster, isn't it? Lets see another scenario: a visit to MacDonald's. What do we end up eating? A fried patty in bread? Still not so bad one may feel. But lets see the accompaniments. A sugar filled cold drink and fried potato chips! Another disaster. What about the people who drink many cups of tea in the day? Not much harm done? Actually lots of harm done if the tea has sugar! All the sugar just ends up in one's belly. 

Secret 4: Portion control. Now we come to the most difficult part of weight reduction. We may be very motivated to lose weight and we may be willing to let go of our tasty snacks, but are we ready for portion control? What does one mean by portion control? It means that one has to control the quantity of food consumed at a particular time.  This is very critical for the major meals which are lunch and dinner. I have devised the 1 to 2 rule. For lunch or dinner one should not consume more than 2 chapati's or 1 chapati and 1 small helping of rice. Obviously this is hugely difficult as we will feel hungry. There are 2 secrets here to succeed. First is to reduce the speed of eating. It takes time for the stomach to send a signal to the brain that it is full. If we eat too fast, we have already over eaten by the time the signal reaches the brain. Vice versa if we eat very very slowly, we will feel full even with seemingly small quantities of food. One should chew slowly and swallow only after chewing the food completely. One should not put another morsel in the mouth till one has swallowed the previous morsel. The second secret is to eat healthy snacks in between meals. So one can have a fruit or a salad or some nuts at 11:00 am and in the evenings at 4pm and if required even at 7pm. If one feels hungry after dinner, one can have a healthy snack at 10pm. This way we can counter the hunger we will feel because of portion control. I must emphasise here that the snack must be healthy! People have a habit of skipping meals and then binge eating at dinner time. They feel proud of skipping a meal and think it will help reduce weight. Then they feel the need for a reward and feel justified in eating a heavy meal. Little do they realise that all the benefit from skipping a meal is not only lost in the binge eating, in fact more harm is done than good. Binge eating can never result in weight loss! The tough truth is that we can never have a heavy meal ever, if we are serious about weight loss! 

This is a sure shot way of losing weight! Many of us feel that we don't eat much food, we eat healthy and still we don't lose weight! But I request you all to introspect sincerely! You must take into account exact quantity of food consumed rather than your best estimate. You must look at the quality of food as well. Learn to pay attention while eating and actually count the chapatis and helpings of rice. Also every small unhealthy snack eaten in between, like a chocolate, a biscuit, a piece of cake or a few chips, matters! 

Armed with these secrets, I am confident that all of us can start losing weight and move towards a more healthy and happy life! 

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Trapezitis

Neck pain is common and most of us have experienced it at some point. It brings with it the anxiety of a serious illness like spondylitis!  Fortunately most cases of neck pain are not due to spondylitis. One of the commoner and less understood causes is trapezitis!

The Trapezius Muscle

The trapezius is a large muscle that forms the nape of the neck. It extends from the neck to upper back and fans out to the shoulder. The muscle has many functions but the most relevant one is to lift the head to look upwards. Any work that requires the head to be stable like working on a computer, reading a book, working on a kitchen table, driving for long or watching television etc. brings the trapezius into action. With our modern lifestyle, one can imagine the extent of overuse and often abuse this muscle faces!

Fatigue and inflammation of this muscle leads to trapezitis. The symptoms are typical. It starts with mild pain or discomfort in the nape of the neck at the end of the day. Initially a good night’s rest solves the problem. In the early stages, massaging the muscle or a hot water bag brings relief. As time passes, the attacks become more frequent and painful. The muscle goes into spasm and feels hard to touch. The pain becomes constant and is not relieved easily. Eventually the pain and spasm can become unbearable. At this point, the patient seeks medical intervention and needs muscle relaxant tablets to decrease the spasm. Understandably this disorder is confused with spondylitis. However it is a different illness with a different approach to treatment.

An acute episode of trapezitis is treated with anti – inflammatory, muscle relaxant tablets. In addition, patients require physiotherapy modalities, a soft cervical collar and rest. A physiotherapist will use interferential therapy (IFT) and short wave diathermy (SWD) to reduce the spasm. The severe pain settles in 7 to 10 days.

We cannot avoid our daily routine and daily work! So how do we protect our trapezius from fatigue and bouts of inflammation? Firstly one must strengthen the muscle so that it can take the rigours of our routine. One needs to do neck and shoulder exercises regularly. Here I will emphasise the importance of doing exercises that involve the hands going above the head (overhead exercises). Swimming is an ideal exercise for trapezitis and regular swimmers seldom get such pain. The second philosophy of treatment concentrates on the ergonomics of work! Poor postures are ripe environment for trapezitis. Working with a laptop on bed or watching televisions lying down are a strict NO. Chairs at work should have a lumbar support. One should sit erect. Avoid slouching. The computer screen should be at eye level. A break is necessary every 20 minutes during long hauls in front of the computer or long drives. One should get up, move around and stretch the neck, shoulders and back.   

Trapezitis is a modern day epidemic brought on by our lifestyle. Awareness of the issue and a logical approach to the problem will help most people avoid it all together!  

The Sunshine Vitamin

As research continues to shed new light, scientists are realizing that vitamin D has many critical functions in the body. It works more like a hormone rather than a vitamin and affects the performance of almost every cell of the body. 

1.      We all know that vitamin D is critical in maintaining adequate amounts of calcium and phosphorus in bones and teeth. In simple words it helps keep bones and teeth strong and protects against osteoporosis and dental caries. However we need vitamin D for many other roles. 

2.      It is important in the regulation of the immune system. It produces anti - bacterial and anti- viral substances and helps fight infections like common cold and influenza. 

3.      It helps to keep the brain functioning normally in later life and prevents mental illnesses like dementia, Alzheimer's disease, schizophrenia and depression. 

4.      Vitamin D helps maintain ideal body weight. Those with vitamin D deficiency are likely to be obese and fail at attempts to reduce body weight via diet and exercise. 

5.      It plays a role in preventing inflammatory disorders like Rheumatoid Arthritis (multiple joint pains), inflammatory bowel disease, psoriasis and eczema. 

6.      It reduces the frequency and severity of asthma and allows for speedy recovery from tuberculosis. 

7.      It reduces the risk of heart attacks and protects against high blood pressure and diabetes. 

8.      Vitamin D has recently been shown to be critical for a normal pregnancy. It prevents pregnancy related illnesses, reduces risk for premature deliveries and reduces infertility. 

9.      It reduces risk of all types of cancer. 

What are the daily requirements of this valuable vitamin? Most authorities recommend around 600 IU of vitamin D daily. Infants less than one year old need 400 IU and adults above 70 years of age need 800 IU.

Now that we realise the critical benefits of vitamin D, we must find out how to get it! Unfortunately getting vitamin D from diet alone is an uphill task. Few foodstuffs are a good source of vitamin D. Vitamin D rich foods include beef liver, egg yolk, certain types of cheese and certain types of fish. One egg gives approximately 40 IU of vitamin D. Unfortified milk (milk is fortified with vitamin D in America and European countries as a government initiative) is a poor source of vitamin D. 

Sunlight is an additional source of vitamin D. It is important as dietary sources of vitamin D are few. Ideally we should get 90% of our daily vitamin D requirement from sunlight. UV rays in sunlight convert a type of cholesterol found in the skin to vitamin D. Modern lifestyle has limited our exposure to the sun. There are many variables that affect the ability of the skin to produce vitamin D. As a result it is difficult to recommend how much sunlight is enough. Most authorities recommend between 5 to 30 minutes of sun exposure to your unprotected face, arms, legs or back between 11 am and 3 pm two to three times a week.  Early morning or late evening sunlight does not work as UV rays are not able to penetrate the atmosphere. Ability to produce vitamin D also depends on the colour of the skin. Fair skin people need less sunlight than darker ones in whom melanin (skin pigment) restricts entry to UV rays. Exposure to sunlight should be direct as UV rays are restricted by glass (window panes) and sunscreen. Weather conditions, cloud cover, pollution and clothing also affect vitamin D production in the skin. At the same time too much sun exposure is detrimental.

Certain groups of people are at higher risk for vitamin D deficiency. These include pregnant and breast feeding women, children between 6 months and 5 years, persons older than 65 and persons who keep their skin covered or stay indoors (don't get enough exposure to sunlight). At risk individuals need to discuss with their doctor and get vitamin D supplements. In America and some European countries, milk and fruit drinks are fortified with vitamin D.

Few sources of vitamin D in diet coupled with poor exposure to sunlight and lack of fortified foodstuffs (especially in India and Asia) makes huge sections of the population at risk for vitamin D deficiency. Everyone should get their blood levels of vitamin D tested. If deficient, appropriate changes must be made in lifestyle to increase exposure to sunlight. If that is not possible, vitamin D supplements are necessary.

Vitamin D deficiency is a modern and very real epidemic that has silently contributed to increase rates of osteoporotic fractures, heart attacks, influenza, rheumatoid arthritis, cancer and premature births! The general public needs to become aware of this hidden deficiency and take immediate corrective measures! 

​Life After Knee Replacement​

Lots of patients are advised knee replacement! But do you really need it? How to really know if you require a surgery? Knee Replacement is a major surgery which should not be taken lightly. It's a great success for those who actually need it and can be a disaster for a  patient who doesn't. The doctor is naturally the best person to make the decision. Sadly many doctors are doing unnecessary surgery for monetary gain. The time has come for patients to become smart! It is my wish that patients become aware enough to decide for themselves. Patients should be able to choose a good decision from a bad one. Enlightening patients has always been my sincere endeavour! 

 

Knee replacement is the final option for a patient with arthritis. It is chosen when all else fails. The patient should have tried all possible treatment methods before considering surgery. Surgery is done for a patient who has constant and severe pain. Pain on getting up from the floor or when going up and down stairs, is common and doesn't usually warrant a knee replacement. However pain during walking is far more serious. Patients who need surgery can barely walk a few hundred feet. Every step is painful. They limp and walk very slowly. Many need a walking stick for support.  Activities of daily living are affected. Such patients tend to remain at home. They will avoid social commitments that require them to leave the house. Getting up at night and going to the bathroom is a huge and painful effort. Painkiller medications are required to get through the day. If you are so disabled and have tried many types of treatments without much benefit, get a knee replacement done.It is a beautifully successful surgery after which you will become normal again. But if you are not so bad, then think again! Knee replacement may not be the best option for you. It may be wiser to wait a while and consider other options. 

 

What has been the experience of patients who have undergone this surgery? Is it really successful? Does it give long term relief? Is the surgery painful? Before surgery, the patients are screened for infection and assessed for fitness. This involves investigations like blood tests, chest X-ray, etc. A physician checks the patient and certifies him or her fit for surgery. The patient is admitted one day prior to surgery. The surgery is done most often under spinal anaesthesia. A small injection is given with a thin needle in the lower back of the patient which makes the legs numb. The actual surgery lasts for 60 to 90 minutes. When the anaesthesia wares off, the patient experiences postoperative pain. The pain is severe for the first 2 to 4 days. Doctors usually have pain management protocols in place to manage the pain like epidural injections, blocks etc. After that the patient gets pain while exercising the knee (lifting the leg, bending the knee) and during walking.  As time passes the pain reduces and completely disappears by 8 to 10 weeks. The patient starts walking on the second or third day after surgery.  Post surgery the patient's leg becomes weak (due to cutting of muscle during surgery). Initially the patient needs a walker to walk. As time passes the leg becomes stronger and the patient can walk independently. Surgery also leads to swelling of the leg and the knee. This is a normal reaction to surgical trauma. The swelling automatically subsides in 12 to 16 weeks. After this period of recovery is complete, the patient truly experiences the benefits of surgery. The Person stops being a patient and becomes normal. He/she has complete relief from pain. He/she can walk normally (and fast) without a limp or stick. He/she does not need pain killers.

 

Even though knee replacement is a major surgery and has a long recovery time, it is a truly gratifying surgery which gives a person spectacular and lasting results.         

What to ask your surgeon?

It is normal to be afraid of surgery. If given a choice, all of us would stay away from surgery. Our reasons for avoiding surgery are obvious. Surgeries come with a baggage of complications. Rarely a complication is severe enough to offset any potential benefit promised by the surgery. The complication itself becomes a bigger problem than the original illness. A complication can happen with the best surgeon having the purest intentions. Therefore it is wise to be scared of surgery. 

Yet we often find ourselves facing surgery. The truth is many problems cannot be solved effectively unless tackled by surgery. Surgery today is far more successful due to improved knowledge, experience and technology. Many patients have undergone surgery and have benefitted tremendously. So if a patient is offered surgery, how should he/she approach the situation?

The first question to be answered is 'Is my problem bad enough?' This is an obvious question and most patients address it correctly. Doing a major surgery for minor issues is a strict 'NO'. Often the alternative non surgical treatments are equally effective. Even though this is a simple decision to make, sometimes patients get carried away by social and economic pressures. I find patients asking for surgery just because they have seen a friend benefit from it or they have the money to buy it! Surgeries are of 2 types: the 'life saving' surgery and the 'quality of life' surgery. With life saving surgeries, the decision is easy. The problem is with 'quality of life' surgeries. For example: a decision to do angioplasty (heart) surgery is easy as it is life saving but a decision to do knee replacement is difficult as it is done to improve quality of life. 

The second question is 'what is the risk-benefit analysis?' Is the benefit promised by the surgery more than the risk of something going wrong or a complication happening. The best surgeries are the ones that offer good results with little risk. For e.g. Knee Replacement completely solves the patients problem (huge benefits) and has a low complication rate. At the other end of the spectrum are surgeries that are new, experimental and unproven. Beware of these as failure rates are high and complications are more.  In between are the surgeries that have proven good results but with a high complication rate. In this situation, I encourage patients to understand the risks completely by a detailed dialogue with the surgeon. 

The next question is 'How good is the surgeon?' This is a difficult question for the patient to answer. As a general rule a specialist will be better. Patients gauge a surgeons skill by his success. Though patients don't have a better way, this method of finding a good surgeon is flawed. Success or fame is multi factorial and a 'famous' surgeon may not necessarily be the most skilled. One effective way is to speak to patients already operated by the surgeon. They often give lots of insight and improve your confidence. 

The last question is 'Have I done my research?' We do a lot of research when we have to buy a new car or a new house. Similarly I encourage patients to do research when they are facing a surgery. Today is the age of information technology and all is available on the Internet. Details of the illness, the success rate of the surgery, the potential complications, the experience of other patients etc need to be researched by patients looking at a surgical option. The procedure should be discussed in detail with your surgeon. I see patients asking questions like 'Is there any guarantee for this surgery?' The answer is obvious and the surgeons who say 'YES' are lying. While this is not a sensible question to ask, there is a list of questions that every patient must ask his/her surgeon. 'What is the percentage of success of the surgery?', 'What are the complications?', 'What are the chances of something going wrong?', 'If a complication occurs, what is its treatment?', 'What is the recovery time?', 'How long will the surgical pain last?' are some of those questions.  

To conclude, everyone would like to avoid surgery but sometimes we cannot. If facing surgery, we should arm ourselves with knowledge beforehand so that we can take intelligent decisions and avoid facing nasty surprises later. 

Frozen Shoulder

Few disorders in Orthopedics affect a patient as dramatically as frozen shoulder does. Most often the pain starts suddenly without any warning. And what puzzles the patient is that the pain starts without any fall or trauma. The pain is severe and is aggravated by any sudden movement of the shoulder. At times the pain is unbearable. The pain worsens at night and patients are unable to fall asleep. They cannot lie down sideways because of pain. The pain is accompanied by increasing stiffness of the shoulder. The patient becomes very anxious because of this catastrophic onset of pain and inability to move the shoulder. 

Frozen shoulder comes with good news and bad news. The good news is that the disorder is self limiting. This means that it is notan ongoing problem like arthritis which ends up with complete destruction of the joint. On the contrary frozen shoulder undergoes a typical evolution from stage to stage and then completely resolves. Therefore almost all patients of frozen shoulder will eventually be completely cured of their illness. Sofrozen shoulder is not a bad disease to have. What then is the bad news? The bad news is that it takes awfully long for the shoulder to get better. Typically a patient suffers for one year to 18 months before the pain goes away. 18 months is a long time for someone to suffer severe pain and sleepless nights!

What is frozen shoulder? In order to understand frozen shoulder we need to understand some simple facts about the shoulder joint. The shoulder is a ball and socket type of joint. Like all other joints the shoulder is strengthened by ligaments and moved by muscles. Similarly the shoulder also has a covering or lining called the capsule. The capsule makes and keeps the lubricating fluid within the joint. In frozen shoulder the capsule gets inflamed and contracted. This inflammation causes severe pain with the slightest movement of the shoulder. The contracture of the capsule causes the shoulder to become stiff. Frozen shoulder in medical terms is also called 'adhesive capsulitis'. We are still not sure why frozen shoulder occurs. However we do know some definite risk factors. It is more common in diabetic patients. It also is more likely to occur in patients who have not moved their shoulder for a long time due to some other reason like an arm fracture or stroke. Frozen shoulder is generally seen in adults above 40 and is slightly more common in women. There are three stages through which the disease progresses before it finally resolves. First is the stage of inflammation. It lasts for approximately 6 to 12 weeks. It is characterised by severe often unbearable pain. In this stage, pain is more prominent than stiffness. The second stage is of stiffness. In this stage the shoulder is very stiff with almost no movement occurring in some patients. The pain reduces in intensity in this stage. This stage lasts for another 12 weeks. The last stage is of thawing. In this stage the disorder resolves. Movements of the shoulder begin to improve and eventually the patient is cured. This stage lasts for 6 to 12 months. 

Are frozen shoulder patients destined to suffer? Is there any treatment for this disease or can these patients help themselves? There is no medicine to cure frozen shoulder. However the disability from frozen shoulder can definitely be reduced. The aim of treatment is to bring back the movements of the shoulder with range of motion exercise. A physiotherapist helps guide the patient through the exercise routine. Once the patients learn the exercises, they continue doing them at home. Those who try to regain movements by exercise are able to reduce pain and shorten the duration of illness. However exercise is many a times extremely difficult because it worsens the pain. Many patients are just not able to do any exercise. We as doctors help patients reduce pain so as to enable patients to do exercise.Initial pain management is with medicines. Tablets are given only with the intention to decrease pain so that patient can do exercise. Exercise remains the mainstay of treatment. If tablets do not work, local injection of steroid medicine is given to reduce the inflammation and pain. One or two injections of steroids do not harm the joint. Repeated injections should be avoided. Sometimes the patients are able to exercise, but are not able to overcome the severe stiffness. For such cases we do a manipulation under anesthesia. As the name suggests, the patient is given anesthesia so that they do not experience any pain. Then the surgeon forcibly moves the shoulder in all directions to loosen the joint. After the manipulation, the patient needs to continue exercise to gain the movements and benefit from manipulation. In very resistant cases, arthroscopic surgery is done to cut the adhesions and allow shoulder movements. 

To conclude, frozen shoulder patients should not be worried about the pain as the problem is self limiting and will get better in time. All attempts must be made to exercise and gain movements with the help of your doctor. Patients who exercise are able to shorten the period of their disability and achieve a cure quickly! 

Heel Spur

Heel pain is a common complaint in my OPD. Patients have lots of misconceptions and needless fear of heel pain. 

As we all know, the bones of the feet form an arch. Only the heel bone and the bones in the front of the foot (metatarsal heads) actually touch the ground while standing or walking. There is a strong fibrous tissue in the sole of the foot extending from the heel bone along the length of the foot. It is called the Plantar Fascia. Plantar Fascia is very tough and takes most of the weight of the body. It acts like a shock absorber. 

Sometimes the fascia gets inflamed especially at the point where it attaches to the heel bone. The condition is called Plantar Fasciitis (Heel Spur). The reason for the inflammation is not clear. It can happen to anybody at any age. It is uncommon in children. This results in heel pain. The pain typically is severe after a period of rest. The first few steps are very painful. As the person continues to walk, the pain decreases. A person with Plantar Fasciitis gets severe pain on taking the first step out of bed in the morning. Then the pain decreases with a few steps. At the end of the day, after walking and standing a lot, the heel becomes painful again. The severe pain (in some patients) and the difficulty in walking generate a lot of anxiety. The inflammation leads to growth of new bone at the area of attachment of the Plantar Fascia. This new bone can be seen on x-ray. It looks like a spur, hence the name - 'Heel Spur'. The name is a misnomer. It is the inflammation of the fascia which is the reason for pain and not the new bone formation. The growth of the bone is a reaction to the inflammation. Therefore surgical removal of the excess bone rarely leads to a decrease in pain!

Thankfully, Plantar Fasciitis is a benign disorder. By that I mean it does not lead to progressive damage of bone or tissue. More often than not the disorder is self limiting. After a period of time which is variable from patient to patient, the Fasciitis resolves by itself. 

There is no cure for this condition. However, as the condition will better itself over time, treatment is directed at reducing pain.  So, how should patients deal with this pain? My first recommendation is to wear soft footwear. One should wear soft slippers at home especially in houses that have a tiled or marble flooring. For outdoors, one should wear comfortable shoes like running shoes. In addition one can use a silicon heel insert in the shoe for added softness and comfort. This simple remedy will decrease pain considerably. Soaking the feet in hot water at the end of the day will also help decrease pain. I also recommend stretching exercises. One effective way to stretch the fascia is to stand on ones toes for 10 to 20 counts. 

In some patients these simple measures do not work. A short course of anti inflammatory medication prescribed by your doctor may help. But taking these medicines for long periods of time has its own problems and is not recommended. For those in severe pain who have no relief with the usual treatment methods, I recommend a local steroid shot (injection). As the steroid is used locally, systemic side effects of steroid medication do not occur. As such, a single steroid injection in the heel is safe. This injection permanently solves the problem for most patients. In a few, the pain recurs after a few months and rarely the injection does not give any relief at all. 

To conclude, Plantar Fasciitis is a disorder that a patient should not worry about. It is not a serious illness. In all probability it will cure itself, given enough time. Simple treatment methods and a few lifestyle modifications will work for most patients. Those in severe pain should opt for the injection as it is safe. Surgery is rarely required and there are no guarantees that it will work. 

Bone Mineral Density

 A common myth among patients is that all bone related or orthopaedic problems are related to a lack of calcium. Daily, I see patients who are taking calcium supplements on their own accord. People especially women feel that they need to take calcium beyond a certain age, or taking calcium will prevent orthopaedic problems in the future. Usually it is a friend or family member that has scared a person into taking calcium supplements. 

It is wrong to attribute all bone problems to calcium. Often the source of musculoskeletal pain is a joint! There are many joints in the body. Everyone is familiar with the large joints like the hip or knee and small joints like the ones found in the hand and foot. There are also lesser known joints like the facet joints found in the spine (neck and back). Inflammation of the joint is known as arthritis. Arthritis has little to do with the lack of calcium. Therefore taking calcium will not reduce joint pain! 

So if lack of calcium does not cause joint pain, then what does a lack of calcium do? A decrease in the calcium content of bones is typically called osteoporosis (different from osteo-arthritis) There are other disorders of calcium like osteomalacia and rickets but these are rare. Osteoporosis affects women after menopause. It is the lack of female hormones (estrogen and progesterone) that leads to osteoporosis. Osteoporosis also affects men but at a later age and less commonly. Osteoporosis is a silent disease. That means that it causes very few or no symptoms. Many patients of osteoporosis will not know that they are suffering from it! This is similar to medical illnesses like diabetes and hypertension (high BP). Time and again the first symptom of osteoporosis is a fracture of the hip or a vertebra (spine fracture). Rarely osteoporosis may cause bone or muscle pain or tenderness (pain on pressing the bone). 

If osteoporosis is a silent disease, how do doctors and patients diagnose it? Like diabetes early diagnosis of osteoporosis is critical as treatment can reduce fracture risk. Earlier it was difficult to diagnose osteoporosis. Doctors would get some idea of bone strength by looking at x-rays of the patient. However x-rays are a crude test as they show osteoporosis only in the advanced stages. By then it is too late! Measuring the blood calcium levels gives no indication of the strength of bones or the level of calcium in the bones. Nowadays technology has improved. A DEXA scan is currently the gold standard for measuring bone mineral density (BMD). DEXA scan checks the density in the lower back and hip which are the critical areas. DEXA scan is a computerised X-ray based test. Ultrasound of the wrist or heel can also be done. Ultrasound is popular as it is portable (used frequently in patient camps) and cheaper. But ultrasound is less accurate and the wrist and heel density may differ from the density in the back and hip. I do not recommend treatment decisions to be made on ultrasound based bone density results. Does everybody need to do a DEXA scan? The answer is NO! The World Health Organisation (WHO) recommends BMD testing in all postmenopausal women above 65 years of age. In post menopausal women less than 65 and premenopausal women, density testing is required only if they have certain medical risk factors (ask your doctor). There is no need for healthy premenopausal women to do a DEXA scan or other BMD testing. BMD testing is also not recommended for healthy men with no risk factors. 

To conclude, I advice my readers to be smart about calcium supplements. Taking unnecessary supplements in the hope of reducing pain is a waste of money. At the same time one should be alert about osteoporosis. Timely BMD testing by DEXA scan is the key. If osteoporosis is diagnosed by a DEXA scan, then treatment with supplements is imperative.
BMD measurements have today become essential for fracture prevention and osteoporosis treatment, but due care is needed in utilising this asset.

Hip Replacement

Arthritis affects the hip joint just as it affects the knee. Hip arthritis is less common in Indians and Asians. One disease that we commonly see is avascular necrosis (AVN). In AVN the blood supply to the head of the femur (thigh bone) is cut off due to some pathology. The most common reasons for AVN are alcohol intake and steroid medication. The dead femoral head loses its round shape and becomes flat and deformed. This leads to destruction of the hip joint and arthritis. Patients have severe pain in the hip. Movements become restricted and very painful.   In advance stages patients have difficulty in walking. They walk slowly with a limp usually with support of a stick or walker.

There are many non surgical and surgical treatments of AVN in the early stages. However in the late stages the only solution is total hip replacement (THR). Similarly end stage arthritis of the hip due to any cause can be successfully treated by hip replacement alone. Hip replacement has been around for more than 60 years. In this time hip replacement has seen a tremendous evolution. Hip replacement can be partial or total. In partial hip replacement, only the ball (head of femur) is replaced. The original cup of the patient is retained. This surgery is typically done for older patients who fracture the neck of femur (hip fracture).

In total hip replacement, both the ball and socket is replaced. This surgery is done for hip arthritis where both ball and socket are damaged. Originally in total hip replacement both components (stem and cup) were fixed to bone with bone cement (cemented hip). The cemented stem (which holds the ball) works very well and has a long life. However the cemented cup lasts only 10 to 12 years. The need to improve life of the prosthesis led to the evolution of uncemented hips. In uncemented design, the cup and the stem are fitted into the bone without using cement. The surface of the stem and cup is made very rough or porous. This allows the bone to grow into the surface. As a result of this bone growth, the life of the prosthesis improves tremendously.  

Originally in total hip replacement, the ball was made ofmetal and the cup was made of high density plastic (metal onplastic). The problem with plastic is that it wears out over time. There has been a big improvement in these materials over the years. The original plastic has undergone a series of changes (highly cross linked) which has improved the durability of the plastic. The biggest change has been the introduction of ceramic. Early ceramic was brittle and had issues of breakage. With later generations of ceramic, the breakage problem was solved. By using ceramic heads instead of metal ones, the wear of the plastic cups is reduced (ceramic on plastic). Then came the ceramic cups. By using a ceramic cup and ceramic ball (ceramic on ceramic), there is very little wear of the cup and the life of the prosthesis is improved drastically. Ceramic on ceramic THR is ideal for the younger patient as it is very durable and lasts a long time. However it is a technically sensitive surgery and has to be done perfectly. It is also very expensive.

Total hip replacement is a life altering surgery. After the initial couple of months which are required to recover from the surgery, the patient starts experiencing dramatic relief of pain. Pain literally and magically disappears. In most arthritic conditions of the hip, the leg becomes short and thisshortening is corrected immediately after surgery. Movements become free and painless. Patient is able to walk normally without a limp or pain. Some patients even manage to run after surgery. In short patients become normal after hip replacement surgery and are cured of their arthritis. With modern surgical techniques and newer prosthetic materials and designs, these patients are able to enjoy their hip replacements for a long, long time.