Health Watch April 27, 2014 by The Times

APRIL 2014

Studies show being bullied impacts adults years later PAGE 11

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Sunday, April 27, 2014

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Physician assistants becoming more prevalent

If you have...

BY ANDREW AKERS

profession especially attractive to the changing health care industry: their focus on general care, which Growing demand for health care, allows them to change specialties partly due to the implementation depending on market needs, and of the Affordable Care Act, is caus- the ability to provide care at a more ing some major shifts in the medi- affordable cost. cal industry. One such change is the “Once we are trained, we have increased prevalence of physician some mobility and flexibility to assistants. go where the market needs us,” he “PAs are really the epitome of said. “We are not locked into one what team health care is about,” specialization for our entire career. said James Cannon, board member “PAs are the provider that can be aakers@gainesvilletimes.com

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PAs are master’s degree-level health care providers who work under the supervision of physicians and surgeons. of the National Commission on Certification of Physician Assistants and a certified PA.“It is an ideal profession for where the Affordable Care Act is taking us.” PAs are master’s degree-level health care providers who work under the supervision of physicians and surgeons.They can examine patients, diagnose injuries and illnesses, perform minor surgeries and assist in major ones, provide treatment and prescribe medications. More than 95,000 certified PAs practice in nearly every medical and surgical specialty across the U.S., and that number is growing, according to data from the commission. The Bureau of Labor Statistics expects the profession to grow 38 percent by the year 2022, more than three times the projected growth rate across all occupations. There are two aspects of PAs, according to Cannon, that make the

at the right place at the right time to provide great care at a good cost.” Many medical providers in Hall County employ PAs. According to the commission, there are 57 PAs employed in the county. Certified physician assistant Coe McGrath works for Dermatology Associates of Northeast Georgia, which has an office off of South Enota Drive in Gainesville. “The primary focus of this practice is the early recognition, education and treatment of skin cancer,” he said.“When I first came here, this practice had a wait time of about six months, and now the wait for a new patient to be seen and evaluated for skin cancer is down to six weeks. “We still think there is room for improvement. As a practice we would like to see that wait under two weeks, so we’ll continue to strive for that.” Nearly every decision a PA makes

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Sunday, April 27, 2014

Doctors you know. Care you trust.

The Longstreet Clinic, P.C. is pleased to welcome Geary Bush, M.D. to the Department of Surgery! Certified by the American Board of Surgery, Dr. Geary Bush is a graduate of the University of Georgia and earned his medical degree at the Medical College of Georgia. He completed his surgical residency at Mercer University School of Medicine. NAT GURLEY | The Times Don and Jo Ann Butler listen to PA Coe McGrath recently at Dermatology Associates of Northeast Georgia. McGrath talked with the Butlers before the exam. “We’ve never even met the doctor,” said Don Butler. “Coe has taken care of everything. It’s been phenomenal.”

is subject to the oversight of his or her supervising physician, which creates a team approach to treatment and diagnoses. According to McGrath, this approach helps increase the effectiveness of treatments. Dermatology Associates currently employs three PAs, which allow patients to be seen and treated earlier as well as have more time to interact with their caregiver. Cleveland resident Don Butler became a regular patient of McGrath’s after undergoing surgery for two cases of melanoma. “We’ve never met the doctor,” he

said. “Coe has taken care of everything. We have had phenomenal success with PAs.” Butler’s wife, Jo Ann, added “quite frankly I would rather see a PA than the doctor because they seem to take more time and are more personal.” The current success of the PA profession could lead to a bright future. “The future is limitless,” Cannon said. “The profession is looking for smart, motivated and patient-centered people, and I think if we continue to attract bright, passionate people, the success is limitless.”

The Longstreet Clinic’s surgeons are experts when it comes to providing a variety of surgical services using the latest minimally invasive techniques. In addition to performing in-office procedures, TLC surgeons have privileges at Northeast Georgia Medical Center and Gainesville Surgery Center. Dr. Bush is accepting new patients in Gainesville! Call 770-536-2323 to schedule an appointment.

www.longstreetclinic.com/general-surgery

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Sunday, April 27, 2014

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Laser imaging offers cutting edge technology for cataract surgery By Alana Swain

The mapped image created by the Verion is especially important in cataract surgery, as each individGainesville Eye Associates is on ual eye is unique. the cutting edge of technology — Doctors can then view this map literally. through their microscopes, allowThe practice last month was the ing them to make incisions and first in the state to use Verion, an perfect placement of lenses based image-guided system that maneu- directly on those measurements. vers the laser during cataract sur“It brings a lot more precision gery to measure specific features and accuracy to the procedure,” of a patient’s eye and create a map said Dr. Jack Chapman, ophthalof it for ophthalmologists. mologist at Gainesville Eye AssociOphthalmologists at the center ates. were already using the LenSx laser, The eye rotates once a person the LuxOR LX3 ophthalmic micro- lies down, so getting the accurate scope and the Centurion vision measurement and rotation of the system to perform laser cataract eye is vital for exact incisions. surgeries. They performed the first The Verion takes a high resolusurgery with Verion March 25. tion image that measures vessels, aswain@gainesvilletimes.com

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SCOTT ROGERS | The Times The new Verion image guided system makes the most precise measurements on the eye available so patients get the most accurate cataract surgery possible.

the iris and other parts of the eye. That image and information are then transferred to the LenSx laser. A live image is then taken of the eye and compared to the reference image and the system rotates until it matches the two images and locks. Once locked, the digital marker system knows exactly where the eye is positioned.

“The LuxOR microscope also has a digital marker on it. We take the same information to it from that reference unit,” Chapman said. “It also registers, compares the two images, and locks onto the eye and tells us exactly where everything is.” “It does a pop-up display-type image on the eye that shows us where everything is,” Chapman

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added. “So that, along with all the information in the computer to help do the calculations, allows us to do everything right there with that one unit.” Chapman said many patients have undergone surgeries with the new system and have responded positively. “We’ve done many patients on it and they’ve all been very excited about it and really appreciate the technology,” he said. Patients are given a choice in regards to cataract surgery. Individuals can elect for the new Verion laser system or the traditional method with a blade. Chapman said more than 50 percent of patients choose the laser version. “Studies have shown that with the laser procedure, you’re cutting through less tissue,” he said. To better help patients grasp the difference in results between the two versions of surgery, Chapman likes to use an analogy.

When installing TV cable in previous years, a wide ditch had to be dug to put in a half-inch of cable. The ditch would then be filled, but a mound of dirt would make it noticeable for about a year. Now, just a tiny trench is built and it’s not noticeable once they finish, Chapman explained. “Patients kind of get that — you’re disturbing less ground to put the cable in and the yard looks better quicker, so the same with this,” he said.“The laser goes in and cuts in between cells, disturbing less tissue compared to the mass of a blade.” Lynn Cole, a technician at the eye center, recently underwent surgery using the Verion system for cataracts in her right eye and said she was pleased with the outcome. “My vision was at 20/30 the day of surgery and one week later, I can see 20/15,” she said.Aside from some slight swelling, a natural effect of surgery, Cole said she recov-

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ered quickly and didn’t experience any pain or discomfort afterward. “Each day things just get better and better. It’s just so hard to believe,” she said. You can find out more about Verion by visiting the Gainesville Eye Associates website, gainesvilleeye.com.

SCOTT ROGERS The Times RIGHT: Mary Saylors gets her eyes measured for cataract surgery by technician Shanon Bradley at Gainesville Eye Associates

Sunday, April 27, 2014

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Fun on the water can result in injury By Alana Swain

vere force from a jump like that,” Ferran said. Those riding Jet Skis should also be aware of potential shock and Those long, hot days of summer injuries when coming down hard are approaching, and with them from jumping a wave. often come hours spent on the “People have injured their backs lake water skiing, wakeboarding and the like that way because that and riding Jet Skis. sudden blow can be rough on the However, countless numbers of joints,” he said. injuries result from these activiAdditionally, in regards to sports ties every year. where a person is being pulled Dr. Harry Ferran, who specialby a rope, shoulder injuries can izes in orthopaedics and sports sometimes be prevented by paymedicine at The Longstreet Clinic ing attention to the intensity of in Gainesville, said there are some the rope’s pull. typical injuries for those water “If it looks like the pull of the sports, such as ACL tears for wakerope is going to cause an injury, boarders, as well as shoulder disthen release the rope so it doesn’t locations and ankle sprains. jerk or pull you and cause damInjuries sustained during wakeage,” Ferran said. boarding can often be attributed Tubing, a popular lake activity to boarders attempting stunts, where an individual is towed in a such as twisting, jumping and tube by a rope behind a boat, can flips, that may be beyond their also pose a risk. skill level. “You’re thrown around and that “They have bindings on the can be very dangerous as far as boots of the wakeboard and, in general, it’s better to keep those head, neck, spine and shoulder inrelatively loose so it doesn’t twist juries,” Ferran said. Overall, Ferran said maintaining the knee or twist the ankle,” Ferran advised. “That way, the bind- good physical conditioning and ings will let the feet come out good strength is often helpful to prevent injuries. Older individuals without any injury.” Water skiing can result in similar should be especially cognizant of injuries, but the sport tends to be potential risks to their bodies. “As you get older, doing these safer than wakeboarding, Ferran more strenuous sports, you’re said. “Ankle sprains and shoulder probably going to be more prone strains are not uncommon, but to some muscle strains, some back generally the more severe injuries pain and possibly rotator cuff don’t occur as often with water tears that younger people would not tend to have as much trouble skiing,” he said. For activities where bones and with,” Ferran said. Injuries seen in younger individjoints experience force from motion, such as hitting the water uals tend to be more from overfrom jumping a wave while on exerting themselves and pushing water skis, making an effort to the envelope when it comes to maintain a good posture can help movement and stunts, he added. As far as any pain from injuries, prevent shock, pain and injury. “In general, keeping the hips Ferran recommends monitoring and knees flexed somewhat will symptoms in case it needs to be act as more of a spring, and there- treated professionally. “If there’s an acute injury and fore take off some of the more seaswain@gainesvilletimes.com

a lot of swelling and bruising or a lot of pain, then probably that should be seen by a physician early on,” he said. “If it’s more of a pain and soreness that you notice the next day and it doesn’t get better within four to five days, it probably would be worthwhile to see a physician to make sure there’s nothing more going on.” In the meantime, acute injuries can sometimes be soothed by applying ice to the injured area, as well as attempting some gentle stretching. For a muscle strain, a heating pad and any type of topical rub can potentially offer relief. NAT GURLEY | The Times Orthopedic and sports medicine specialist Dr. Harry Ferran checks Debbie Esco’s shoulder at The Longstreet Clinic recently.

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New hearing aid designed to work with iPhones Andi Eckardt

Gainesville Hearing Aid Center’s owner, Stan McDaniel, was present for the trials and had good reviews on the product. “The sound quality is great. I saw a One of the latest advances in hearing aid technology is a new device engineered demonstration from the manufacturer, and specifically to be compatible with iPhones the product is taking the industry in a good direction,” McDaniel said. and other Apple electronic devices. The hearing aid’s volume can be controlled All-American Hearing Aid Centers in Gainesville is one of the first hearing aid through whichever Apple device is being specialists to offer the new technology, used, with the sound settings personalized to which uses an app to interface with the various environments and up to 20 location settings saved in the iPhone. iPhone. The product works for any type of hearing Earlier this month, the company began offering the Audibel A3i, which is designed loss, no matter the age. The hearing aid acts specifically to be compatible with Apple just as noise cancelling headphones would with an Apple device. products. McDaniel said the device is especially userThe practice has been working with Apple for several years to develop the device and friendly for those who already use an iPhone. Aside from the Apple technology, the accompanying app, which allow iPhone, iPad or iPod Touch users to listen to music, video Audibel A3i works as a standalone hearing chat using Apple’s FaceTime and stream aid featuring noise cancellation and adaptive phone calls while eliminating outside noise. noise management, controlling how much The manufacturer of the new hearing aid has outside noise to cancel out. For more information, visit TruLinkHearing. conducted multiple trials that have allowed potential customers to test the product. The com aeckardt@gainesvilletimes.com

Sunday, April 27, 2014

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Sunday, April 27, 2014

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Mayo Clinic technique improves outlook for breast cancer surgeries By Dan Browning

Star Tribune (Minneapolis) Mayo Clinic likes to say that its team-based, patient-centric approach to medical care increases value. On April 9, it released the latest evidence — research showing that a novel technique improves outcomes for women with breast cancer, the nation’s No. 2 cause of death for women, after lung cancer. Mayo’s unique method of pathologic evaluation when removing cancerous tumors from breast tissue — a lumpectomy — is so effective that just 3 percent of patients require a second surgery to track down missed cancer cells, according to a study released by the journal Surgery. That compares with a national rate that ranges between 15 percent and 40 percent — raising the prospect that surgeons could reduce the stress and infection rates associated

with additional surgery and improve the breast cancer resection process. Mayo’s method of performing a lumpectomy involves a team of specialists, including pathologists who perform tests on the excised lumpectomy specimens while the patient is still on the operating table. By freezing an entire tumor and taking slices from around its periphery, they can determine within 20 to 30 minutes whether the surgeons need to cut away more tissue to be certain that they’ve removed all of the cancerous cells. “In breast cancer, what I think is critical is that multidisciplinary team,” said Dr. Judy Boughey, a professor of surgery at Mayo who was the article’s lead author. “The pathologists here are making me look good ... because I’m doing the same (excision) procedure I would do anywhere else.” Mayo developed the method for

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freezing tissue samples more than 100 years ago. Asked why it published a paper about it now, Boughey said: “We’re really looking to show people the value of what Mayo provides. It’s cost. It’s patient care. It’s minimizing reoperations, improving patient experience.” The need to reward value rather than volume in U.S. health care has been a frequent theme of Dr. John Noseworthy, Mayo’s CEO, who contends that Mayo’s method of using interdisciplinary teams provides high-quality care at relatively lower costs by reducing duplication of procedures, readmissions and errors. The lumpectomy study compared Mayo’s own surgical results with 24,217 lumpectomies tracked by the American College of Surgeons and found that patients nationally were more than four times as likely to need a second operation. The new study follows a 2011 ar-

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ticle by Mayo authors in the Annals of Surgical Oncology that found that Mayo’s frozen-tissue analysis takes a bit longer but can save costs overall. The study concluded that analyzing frozen tissue from breast lumpectomies is labor-intensive and can’t be done at every hospital. But for cancer centers where it’s feasible, it can save money for providers and payers, “and importantly it can also dramatically improve patient experience.” The average nationwide cost for a medical institution to remove an entire breast tumor ranged from $4,835 to $6,306. Mayo’s average was $5,708, which was less expensive, on balance, when the reoperation rate exceeded 36 percent. The cost to payers, such as Medicare, ranged from $3,577 to $4,665 nationwide and averaged $3,913 at Mayo. Its method was less expensive for payers when the reoperation rate exceeded 26 percent.

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Sunday, April 27, 2014

Victims of bullying live with the consequences for decades, study says Back in the 1960s, when the study subjects were 7 and 11 years old, researchers interviewed their parents about bullying. Parents reported whether their children were never, sometimes or frequently bullied by other kids. Fast-forward to the 2000s. About 78 percent of the study subjects are still being tracked at age 45, when they are assessed for anxiety and depression by nurses. By the time they’re 50, 61 percent of them remain in the study, and are asked to fill out a questionnaire that measures psychological distress. The researchers found that people who were bullied either occasionally or frequently continued to suffer higher levels of psychological distress decades after the bullyBy Karen Kaplan ing occurred.They were more likely Los Angeles Times than study subjects who were never bullied to be depressed, to assess Victims of bullies suffer the psy- their general health as poor, and to chological consequences all the way have worse cognitive functioning. until middle age, with higher levels In addition, those who were bullied of depression, anxiety and suicide, frequently had a greater risk of anxinew research shows. ety disorders and suicide. The immediate ill effects of bulThe consequences of bullying lying have been well documented, were economic as well. Study subwith experts increasingly seeing it jects who had been bullied freas a form of child abuse. Influential quently had fewer years of schoolstudies from Finland have made the ing than their peers, the researchers case that people who were bullied found. Men in this group were more as kids continued to suffer as young likely to be unemployed; if they had adults — girls who were bullied jobs, their earnings were typically grew up to attempt and commit sui- lower. cide more frequently by the age of Adults who were bullied as kids 25, for instance, and boys were more were more socially isolated too. At likely to develop anxiety disorders. age 50, bullying victims were less Now a trio of researchers has taken likely to be living with a spouse or an even longer view. They examined a partner; less likely to have spent data on 18,000 people who were time with friends recently; and less born in England, Scotland and Wales likely to have friends or family to during a single week in 1958 and lean on if they got sick. Overall, they then tracked periodically up through felt their quality of life was worse the age of 50 as part of the U.K.’s NaPlease see Bullied page 15 tional Child Development Study.

Elia G. Abboud, MD Joon Ahn, MD Mitchell G. Davis, MD Allison G. Dupont, MD Abhishek Gaur, MD Brenda J. Hott, MD Jay H. Joseph, MD

Christopher R. Leach, MD Mark E. Leimbach, MD J. Jeffrey Marshall, MD Mark A. Matthews, MD Lalitha C. Medepalli, MD Gary M. Minkiewicz, MD Kashyap B. Patel, MD Salem N. Sayar, MD

Timothy A. Scully, MD Mehrdad S. Toosi, MD Prad E. Tummala, MD S. Steven Wang, MD Heather B. Westmoreland, MD Mark W. Wolozin, MD Andrew D. Yen, MD

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Sunday, April 27, 2014

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Variety of factors can cause foot pain By Charles Phelps

cphelps@gainesvilletimes.com Foot pain, no matter how little it hurts, can be disruptive to a person’s everyday life. If not treated, it can lead to more aches and pains throughout the leg, like the ankle and knee, said Dr. Holmes B. Marchman of The Longstreet Clinic. He explained people with foot pain over time can start limping without noticing, and it will change the way a person walks as they get around the pain. “There are a ton of things that can cause foot pain,” he said. Marchman grouped foot pains into three areas: the toes, arch and heel. Some heel pain comes from what’s known as plantar fasciitis, Marchman explained, where connected tissue on the sole, or bottom of the foot,

near the heel, starts to have little tears, causing pain. This normally leads to the start of heel spurs. If you develop a heel spur, an orthotic foot pad, over-the-counter or specially-made, can help relieve pain; medicine and/or an injection into the heel will help reduce inflammation, Marchman said. “Only a surgery can fully get rid of heel spurs if the pain persists,” he said. Other things that cause pain in the heel, he said, are high arches in one’s foot and poor arch support. Weight issues and radical changes to one’s workout can affect pain levels. People who experience arch pain, which Marchman referred to as “spontaneous” pains, can look at shoes as the main culprit since Please see Foot pain page 15

NAT GURLEY | The Times Dr. Holmes Marchman looks at the X-ray image of a foot at The Longstreet Clinic’s Physical Medicine and Rehabilitation center. Marchman said the foot has a fracture to the distal hallux — the big toe.

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Beta-blockers prescribed for variety of heart problems By Charles Phelps

cphelps@gainesvilletimes.com When someone with a heart condition goes to the doctor, their blood-pumping nervousness could be eased when they find out surgery may not be required for their condition. According to cardiologist Dr. Elia G. Abboud of the Northeast Georgia Heart Center, betablockers have been an effective treatment for nearly 50 years and are still used today.And if surgery isn’t needed, they can help balance a heart condition. Among the heart patients who use them are those who suffer from congenital heart disease and failure, high blood pressure and atrial fibrillation, Abboud said. “Beta-blockers are a category of medication to which some people refer as the ‘cardiac jack of all trades,’” Abboud said, “because they have stood the test of time and have so many benefits.” There are three categories of beta-blockers — early generation, second generation and third generation — each of which affect different parts of the heart. Some of the benefits include increased mobility, improvement with strength and function of the heart and extension of lives, he said. Someone with congenital heart disease and failure will take a third-generation blocker, which will improve the strength and mechanical function, or pumping of the heart, Abboud said. For someone with high blood pressure, blockers are the “cornerstone of treatment,” he said. For those who suffer from atrial fibrillation, blockers help the electrical function of the heart,

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or the heart rate. “If the heart rate goes too fast, the blockers will help slow it down and put it back in rhythm,” he said. However, Abboud said someone with atrial fibrillation and on blockers is more at-risk to suffer a stroke. Other side effects include fatigue and asthmatic-like symptoms, making it harder for the patient to breathe. “I wouldn’t give it to someone with a low heart rate because it can cause dizziness and blackout spells,” Abboud said. “If you suffer from depression, don’t use blockers, because it can cause flare-ups big time.” He also said those who suffer from poor circulation in the legs also should not use blockers.

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Infant organ donations can save lives By Susan Schrock

valves to possibly help other children in need. “My husband and I said ‘yes.’ We didn’t Simon Alexander Garcia lived only one hesitate,”Whitworth said. brief hour. But somewhere a little girl’s It wasn’t until last week that Whitworth heart is beating today because of him. and Garcia learned that one of Simon’s Kim Whitworth and her husband, heart valves went to a little girl at a Dallas Michael Garcia, were devastated to learn hospital in February. at their 20-week ultrasound examination “When I found out, I was overjoyed. I last year that their first child’s lungs and broke down in tears,” said Garcia, 22. “He bladder were developing abnormally. died for a purpose. I knew he was going Though they knew he would not survive, to help someone out. I was overwhelmed the Fort Worth, Texas, couple chose to by the love God has.” continue the pregnancy. Simon was born Simon’s family shared their story this just before midnight June 28 at Texas month during a ceremony at the hospital Health Harris Methodist Hospital Fort aimed at raising awareness of the critical Worth, two weeks ahead of his expected need across the state and country for due date. organ and tissue donors. April is National “He had so much hair it was hard to Donate Life Month. Since 2010, the believe,” said Whitworth, 21. “Everyone hospital has annually recognized donors was amazed at how beautiful he was.” such as Simon and recipients by adding Not long after Simon took his final their names to the Wall of Life. breath, his parents were asked whether “There are a lot of people who have they would consider donating his heart lost a loved one tragically. Everyone has Fort Worth Star-Telegram

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their own way of dealing with it,” said Whitworth, who encouraged people to consider organ donation. “But I think if you can do it, do it. It gives you hope that maybe your loved one can live on in someone else.” “Across the country every day 75 people are saved through the gift of life, through transplantation,” said Laura FrnkaDavis said, spokeswoman for the Houstonbased LifeGift, a nonprofit procurement group. “We continue to push people to become registered donors,” Frnka-Davis said. Donors can help as many as eight people through organ donation and can help improve the lives of 50 people or more through tissue donation, according to LifeGift. About 1,800 children nationwide are among the 120,000 people waiting for an organ transplant, according to Donate Life America. Last year, 139 organ donors

Ron Jenkins/Fort Worth Star-Telegram/MCT Kim Whitworth places her hand near the name of her baby, Simon, at Texas Health Harris Methodist Hospital Fort Worth. Simon’s name has been added to the hospital’s Wall of Life

across the country were younger than 1, according to the United Network for Organ Sharing. Statistics on infant tissue donors were not available. Whitworth said she hopes that one day she can meet the little girl whose life Simon touched. “I would absolutely love that,” she said.

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Bullied

Foot pain

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than people who hadn’t been bullied, and those who had been frequent victims were less optimistic that their lives would get better in the future. Overall, 28 percent of the people in the study were bullied occasionally as kids, and an additional 15 percent were bullied frequently. Boys were more likely to be victims than girls. “The findings are compelling in showing that the independent contribution of bullying victimization survives the test of time,” the researchers concluded.“The impact of bullying victimization is pervasive, affecting many spheres of a victim’s life.” The study was published online by the American Journal of Psychiatry.

some don’t fit well or give proper support. “There are models of shoes that manufacturers specifically make to support runners,” he said. “It’s a good idea for a normal runner to go to a shoe store and get good running shoes for themselves. “This class of shoe allows the foot to move the ways it’s supposed to.” Marchman said people should research good shoes and talk to a foot specialist, as well, about what shoes could help. A person can also use an orthotic pad to help relieve pain, like with the heel spur. “The goal is to combine support for the arch and support for the heel and foot to relieve pain off the foot and ankle,” he explained. Besides an orthotic pad, simple

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ways to help reduce inflammation and pain include ice water soaks and foot massages. Heat can help but he cautioned that if the pain is new, heat should not be used. Another thing people should

Sunday, April 27, 2014

dried-out feet will begin to crack, he explained. If a crack happens in the foot, infection can set in without the person knowing, he said. Nondiabetics could experience

Dried-out feet will begin to crack... If a crack happens in the foot, infection can set in without the person knowing. watch for is nerve damage. According to Marchman, diabetics are at the most risk of nerve damage, or diabetic neuropathy. “They can lose sensation (feeling) and protective sensation in the foot,” he said. If someone gets a rock in their shoe, they might not feel it, and

nerve damage, but mainly between the toes. “Knees, ankles, feet are a kinetic chain,” he said. “All of the different joints, tendons, toes, work together, and if they are not working normally, then they can make other things experience pain. “And they aren’t easy to rehab.”

Sunday, April 27, 2014

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