Medical Insider Blog

Treatments for Tendon Pain

  • Posted Mar 05, 2015
  • Fernando Manalac, MD, MMM

What are Tendons?
Tendons are the stretchy, white bands of connective tissue that are at the ends of muscle and connect the muscle to the bone.

How a Tendon Causes Pain
When a tendon is stretched or eccentrically overloaded, the fibers can tear. This is called strain. Other types of tendinopathy (disease of a tendon) include tendinitis and tendinosis. Tendinitis is acute inflammation of a tendon. Tendinosis is degeneration of the tendon fibers from repetitive microtrauma resulting in the development of abnormal tendon tissue. The commonality amongst these tendon problems is that they can all cause significant pain and dysfunction, keeping people from doing the recreational activities they need or the work that needs them.

Treating Tendon Pain
In the not-so-long-ago past, treatment plans for these tendon problems were very limited: rest, ice, compression and elevation were, and still are, the best initial therapeutics. NSAIDS and other medications and modalities are also used to reduce inflammation and can be very beneficial. Prescription medications and cortisone injections may have a limited role in persistent tendon pain or inflammation. However, nothing has been shown to be more effective than eccentric exercise in physical therapy at repairing damaged tendon. 

What if Treatments Have Not Worked?
What do you do if none of these therapeutics have worked? From the 1970s-2000s, advanced treatment for tendinopathy was limited to surgery. Surgery is still the only clear fix for complete ruptures of tendons; meaning, if a tendon is torn in half, the only way to get perfect function is to reattach those two ends. However, performing surgery on strains (partial tears) that won’t heal, or refractory tendinoses, may actually be excessive.

Orthobiologic injections, such as Platelet Rich Plasma and Mesenchymal Stem Cells and minimally invasive techniques, such as percutaneous tenotomy, are revolutionizing the advanced treatment of tendinopathy.

Schedule an appointment with Dr. Manalac to discuss if one of these therapeutics might be appropriate for you and can get rid of your tendon pain once and for all.
Dr. Manalac is a non-surgical sports medicine physician who practices in Fort Lauderdale. For referral information, call 954-776-9517.


Diagnosis and Treatment of Alzheimer’s Disease

  • Posted Jan 29, 2015
  • Eduardo R. Locatelli, MD, MPH

According to the Alzheimer’s Association, someone in the United States develops Alzheimer’s Disease every 67 seconds and by 2050, the number of people age 65 and older with the disease may nearly triple barring the development of medical breakthroughs. In today’s healthcare world, the diagnosis and treatment of this disease involves:

Hearsay Evidence: Talking with the patient and a family member or friend who can corroborate the patient’s memory loss is the first step to determine if physical and cognitive changes are part of the normal aging process or if they are indicative of mild cognitive impairment and Alzheimer's.

Process of Elimination: There is no definitive test for Alzheimer’s despite decades of research. Eliminate other possible causes of memory loss is the first step in diagnosing this disease. Depression is a common disease that occurs as we age and someone with severe depression can appear to have Alzheimer’s. Parkinson’s disease also shares common symptoms. The list goes on, and even sleep medications and analgesics taken for the aches and pains of aging can make us forgetful.

Technology: Not one of the many state-of-the-art medical devices in healthcare today treats Alzheimer’s. They are merely tools we can use to confirm a diagnosis.  MRI brain imaging can help rule out hydrocephalus and benign or malignant tumors as well as damage caused by silent strokes. Low-tech blood tests are used to uncover low thyroid, vitamin deficiencies and liver and kidney conditions that can cause memory loss.

Pills, Patches and Ipods: Although research has failed to give us a good medication, it has created multiple lines of treatment which offer, if anything, modest improvement. The FDA has approved medications from two classes (cholinesterase inhibitors and memantine), and alternative treatments include vitamin and food supplements. While many of these can be quite expensive, increasing socialization, exercise and just listening to music have also shown improvement in brain function. 

Research: As with diagnosing the disease, research to date can be seen as ruling out possible biological markers or genetic profiles. MRI’s are looking at the size of memory centers in the brain as PET scanning is being performed to understand if abnormalities in glucose metabolism create plaques in the brains of older individuals. Genetic research is investigating the apolipoprotein E (APOE) gene found on chromosome 19. According to the NIH’s National Institute on Aging, most researchers believe that APOE testing is useful for studying Alzheimer's disease risk in large groups but not for determining an individual’s risk. In practice, APOE testing is considered for patients with a family history of early-onset Alzheimer's disease but is not generally recommended for people at risk of late-onset Alzheimer's.

Dr. Eduardo R. Locatelli is the medical director of the Holy Cross Neuroscience Institute and of Holy Cross Hospital’s Epilepsy Monitoring Unit. For referral information, call 954-776-9517.

Ask the Doc - Audrey Liu, MD, Internal Medicine: Shingles Vaccine and Chickenpox

  • Posted Jan 26, 2015
  • Audrey Liu, MD

Q: Can the shingles vaccine give me chickenpox?

Dr. Liu: Since Zostavax is a live virus, there is a theoretical possibility that a person who has been given the shingles vaccine can shed the weakened virus, which theoretically could give someone chickenpox. This has never been reported as an actual occurrence, but if a rash occurs at the injection site, this rash is potentially contagious. The patient should keep the rash covered and avoid contact with pregnant women, infants and immunocompromised patients until the rash clears.

Dr. Audrey Liu is an internal medicine physician who practices at the Holy Cross Medical Group Pompano Beach Practice. For referral information on Dr. Liu, please call 954-776-9517.  

Rare Brain Tumor Removed, Patient on Road to Recovery

  • Posted Jan 22, 2015
  • hchadmin

For months, Kathleen Cruz, 64, would have sudden onset headaches when she bent over. A legal secretary, she attributed her symptoms to stress.

The excruciating headaches on December 16, 2014 sent her to the Emergency Department at Holy Cross Hospital…but only after weeks of headaches accompanied by hand tremors, being off-balance, weight loss and nausea.  

Hemangioblastoma Imaging Photos Two ViewsDoctors found a mass on her cerebellum. The rare tumor – a hemangioblastoma  – was pressing on her brain stem, causing her symptoms and headaches. Of more concern, the tumor was obstructing the passage of spinal fluid from her brain, elevating the pressure in her head—a diagnosis called hydrocephalus, which if left untreated could have killed her in a matter of weeks. Brain surgery was required, not only to remove the tumor but to also relieve the hydrocephalus. Using the StealthStation® Surgical Navigation System, specially designed for surgeries in the complex and delicate areas of the spine and brain, Dr. Ali Jourabchi Ghods removed the mass, later deemed benign.

“When I first saw Mrs. Cruz in the ER after reviewing her CT, I thought she may have a malignant brain tumor or metastasis based on just sheer location and chances,” Dr. Ghods said. “However, after the MRI was completed, it looked suspicious. It had the classic appearance of a hemangioblastoma, which is very rare. In 7 years of training at a large university hospital, I have only seen this type of tumor one time. Additionally, they tend to occur in younger people. I assured both Mrs. Cruz and her husband, Rolando, that based on the MRI, I was hoping we were dealing with a hemangioblastoma because surgery was 100% curative, versus something more aggressive such as metastasis. During surgery, it was obvious this was a vascular tumor and when our pathologist said this was a hemangioblastoma, we had the good news delivered to Rolando. We took the tumor out in its entirety and in the same sitting cured her of her hydrocephalus. She was a champ in the OR and a champ after, and went home without any complications or setbacks.”

“I was comfortable with him,” Mrs. Cruz said of Dr. Ghods. “Everything he said came through. Dr. Michael Rush made sure I got the CAT scan right away. Another 2 to 4 weeks of this and I could have gone into a coma.”

When she came for a follow-up visit three weeks post-surgery, Mrs. Cruz was looking healthy and inquiring about resuming yoga.  Although she works in Fort Lauderdale, Mrs. Cruz’s full-time residence is in Port Charlotte—more than 150 miles away on Florida’s west coast— where she is resting and recovering under the watchful eye of her husband, who is now a Holy Cross enthusiast.  “Thanks to Dr. Rush and Dr. Ghods, Holy Cross is now my first choice,” Mr. Cruz said. “Dr. Ghods is someone very special. He is enthusiastic, caring, aggressive, loving. He was on the money. He knows what he is doing.”  

“She is the Eveready Bunny,“ Mr. Cruz said of his wife. “She never stops.”  And thanks to the team at Holy Cross Hospital, she can keep going. 

Dr. Ali Jourabchi Ghods is a neurosurgeon who practices in Fort Lauderdale, FL and is a member of the Holy Cross Medical Group. For more information on Dr. Ghods, call 954-776-9517.

Healing Diabetic Foot Ulcers: It Takes a Village

  • Posted Jan 14, 2015
  • Carlos O. Guerra, MD, MPH, CWSP

Hyperbaric Oxygen Therapy

In my particular field, infectious diseases, I have the chance to diagnose and treat infected wounds and osteomyelitis in conjunction with hyperbaric oxygen therapy. Along with a panel of wound experts in various specialties, we work together in healing chronic wounds.

Diabetic Foot Ulcer
One of the most challenging types of chronic wounds that I see every day is the diabetic foot ulcer.
A few quick facts:
•    Diabetes affects over 26 million people in the United States.
•    Foot wounds are the most common diabetes-related cause of hospitalization that could result in amputation.
•    Patients with diabetes have a 25 percent higher chance of developing a foot ulcer.
•    Patients with diabetes have a 50 percent higher chance of developing an infection compared to the general

Treating Diabetic Foot Ulcers
A multidisciplinary approach is essential to preventing complications of diabetes. Podiatry services are needed for prevention, education and treatment of diabetic foot ulcers; infectious disease services for diagnosis and treatment of infected wounds and osteomyelitis; and vascular services and general surgery services are also needed because many patients with diabetes have peripheral vascular disease.

The Holy Cross Wound Healing and Hyperbarics Center utilizes the expertise of these wound experts to offer different modalities of wound healing, from appropriate dressings to skin substitutes, periodic surgical debridements, and revascularization procedures for severe peripheral vascular disease ulcers. Hyperbaric Oxygen Therapy is also offered for patients with diabetic foot ulcers with chronic refractory osteomyelitis, often in conjunction with long-term antibiotics. In addition, emphasis on prevention, off-loading and education regarding diabetes and diabetic foot infections is given to all patients. We also follow up with patients at the Center every week until the wound is completely healed.

Dr. Guerra is an infectious disease specialist who practices in Fort Lauderdale, FL and is a member of the Wound Panel at the Holy Cross Wound Healing and Hyperbarics Program. If you or a loved one has a nonhealing wound and would like to speak with Dr. Guerra or learn more about the Holy Cross Wound Healing and Hyperbarics Program, call 954-776-9517.

Acute Inpatient Rehabilitation Versus Skilled Nursing Facility Rehabilitation

  • Posted Dec 23, 2014
  • Renee Hinson-Smith, MSOTR/L

When you are preparing for discharge from the hospital, your health care team may recommend continued care before you go home. Going to “Rehab” after discharge can refer to Acute Inpatient Rehabilitation or rehabilitation in a Sub Acute Skilled Nursing Facility.  There are important differences which may not be clearly defined in the glossy brochures left at your bedside.  At a quick glance it appears that both types of Rehab offer therapy, physician and nursing care with programs designed for a variety of illnesses and post surgical recovery.  It is important that you understand the differences so that you and your family can better participate in making important decisions about your post hospital recovery plan.

What’s the Difference?


Acute Inpatient Rehabilitation Facility (IRF)

Because the IRF provides such a high level of intensive therapy as well as specialized nursing and physician care, Medicare and private insurances have established eligibility requirements for admission.  There are fewer requirements placed on sub acute programs.  The discharge planning team can assist you in determining if you are eligible for either type of Rehab program.

Skilled Nursing Facility / Sub Acute SNF

Sub Acute SNF programs are a part of the skilled nursing community which includes both short-term sub acute rehab and the residential portions of the Skilled Nursing Facility. Some facilities separate the two patient population rooms and therapy areas while others are comingled. In most instances,  the common areas such as dining and recreation are comingled.


Both types of facilities perform an evaluation shortly after arrival.  The sub acute evaluation will place each person in a category, which determines the amount and types of therapy minutes a patient will receive. The minutes allocated after evaluation can vary from a high of 12 hours down to a total of 45 minutes per week. Patients are re-evaluated and the therapy minutes adjusted on or around days 5, 14, 30, 60 and 90.  The IRF Evaluation is completed by the 3rd day.  The evaluation process helps the IRF target a discharge window of time for each patient.  Therapy is provided at least 3 hours a day at least 5 out of 7 days or 15 hours per week at minimum.  Each person is followed by a multidisciplinary team which meets formally at least every 7 days to address any barriers found which might change the discharge plan.   No changes are ever made in the amount of time patients receive therapy.

Differences in Medical and Nursing Care

Medical care is available at both types of facilities.   The availability of physicians and nurses is quite different.  Medicare patients in the Acute IRF must be seen in person by rehabilitation physicians  (physiatrists) at least three times per week. At Holy Cross Hospital, patients are seen by a physiatrist every day during the week, and a physiatrist is available on the weekends as well.  By contrast, Medicare patients in some sub acute rehab SNF may not see a physician more than once a week or in some instances even longer.  If the IRF is a part of the acute care hospital, the patient will have their primary physician and any clinical specialists that followed the patient in the hospital available to them during their IRF stay. In the event of an emergency,  the services of a full acute care hospital are available without delay.

Nursing care in an acute IRF facility is available 24 hours a day by a registered nurse with special training in rehabilitation care. Sub Acute SNF facilities are required to provide a registered nurse at least 8 hours a day and a licensed nurse the remainder of the time. Any emergent medical circumstances require that the patient be transported to the nearest acute care hospital by ambulance.

At the Holy Cross Hospital Rehabilitation Institute, our 48-bed inpatient rehab unit provides highly trained individuals working as a team to address the post acute care recovery of the individual. Specialists and primary care physicians familiar to the patient are able to continue any follow-up care, and there is a rehabilitation physician who provides daily medical management to each patient. Of course, not every patient requires this high level of intensive rehabilitation after hospitalization. 

Ask your case manager or physician to determine if you are a candidate for the Inpatient Rehabilitation Unit of Holy Cross Hospital. If you have any questions, call 954-351-5958.

Renee Hinson-Smith, MSOTR/L, is a licensed occupational therapist and the director of Holy Cross Hospital’s Inpatient Rehabilitation Unit. She obtained her Master’s Degree from the Medical College of Virginia. Renee has served Holy Cross’ healing ministry for 16 years. Learn more about the Holy Cross Rehabilitation Institute by visiting

Carpal Tunnel Syndrome

  • Posted Dec 15, 2014
  • Kathryn A. H. Heim, MD

What is Carpal Tunnel?

Healthy Carpal Tunnel v Median Nerve Compression
Several nerves supply feeling and function to the hand. One of these nerves, the median nerve, passes through a small canal near the wrist called the “carpal tunnel” along with several tendons that go to the hand.  When the median nerve gets pinched inside the tunnel, this condition is known as carpal tunnel syndrome.


The most common symptom of carpal tunnel syndrome is numbness and/or tingling in the hand, specifically in the thumb, index, middle and part of the ring finger. Patients with this condition often wake from sleep with tingling and the need to shake their hand to relieve the symptoms. Some patients also have pain that travels up the arm from the hand. 


A variety of other conditions may also cause numbness and tingling in the hands, and a physical exam by a doctor along with nerve testing can help to determine what is causing your numbness and tingling. 

Talk to your doctor if you suffer from the above symptoms regarding possible treatment options.

Dr. Heim is an orthopedic surgeon who specializes in hand and upper extremity conditions. She practices in Lighthouse Point and Boca Raton, FL. For a physician referral, call 954-776-9517.

Inguinal Hernia

  • Posted Dec 02, 2014
  • Christopher Seaver, MD

Source: EbscoInguinal hernias are one of the most common surgical problems in the United States and account for over 600,000 annual procedures.  An inguinal hernia may be defined as a defect in the lower abdominal wall or groin that results in a protrusion of abdominal contents.  Symptoms are variable and range from a simple groin bulge to severe abdominal pain. Consequences of an advanced or strangulated (non- reducible) hernia may be severely morbid or even life threatening. Not all inguinal hernias require repair, however. If symptomatic, they are usually in need of surgical evaluation. Lifetime risk for males and females are 27% and 2% respectively.

Inguinal Hernia Repair

There have been multiple advances in inguinal hernia repair and the latest options include traditional open repair, laparoscopic/minimally invasive (MIS) and robotic-assisted repair.  The underlying principle in all methods of repair involves placement of a permanent mesh covering the defect. The method of repair depends on surgeon experience, primary vs secondary occurrence and medical-surgical history.  As technology has evolved, minimally invasive repair (including robotic repair) has shown equivalent short-term outcomes in terms of recurrence, compared to traditional open repair.

Major Advantages of Minimally Invasive Repair (Including Robotic Repair)

● Better outcomes in terms of long-term recurrence

● More rapid return to full activity

● Less pain

● Smaller incisions

Traditional repair requires avoidance of strenuous activity for nearly two months vs only 2-5 days with MIS. Furthermore, as many as 15% of patients have bilateral hernias(both groins) that can be repaired through the same small incisions with MIS vs two large groin incisions with traditional repair.

In the hands of a skilled MIS surgeon, laparoscopic and robotic assisted inguinal hernia repair has clearly become the repair of choice. If you believe you are experiencing the symptoms of an inguinal hernia, please visit your primary care physician or a general surgeon. If the pain is severe or disabling, urgent evaluation in an emergency room is necessary.

Dr. Seaver is a general surgeon who practices in Fort Lauderdale, FL and specializes in minimally invasive and robotic-assisted general surgery. For a physician referral, call 954-776-9517.

Platelet Rich Plasma (PRP) Therapy

  • Posted Nov 07, 2014
  • Fernando Manalac, MD, MMM

Used by professional and recreational athletes alike, platelet rich plasma therapy is used to regrow/heal tissue that is not healing or not growing. This therapy is done to address situations that in the past have required surgery.

This procedure is completed within 45 minutes in my office. Your blood is drawn and placed in a centrifuge that spins and separates the platelets and a little bit of white blood cells, and some of the plasma.

The platelet rich plasma concentration is then injected back into a very focused and specific part of the problem area using ultrasound / imaging guiance. In each platelet lives alpha-granules which contain all of the growth factors you need to heal or grow tissue. Following this procedure, physical therapy and other modalities are necessary.

PRP injections can be done for treatment of partial tendon tears, ligament tears, cartilage injury and osteoarthritis.

More information on this procedure, including what patients can expect after a PRP injection may be found in my interview below:
PRP Injection Video Screenshot

Dr. Manalac is a Primary Care Sports Medicine physician who practices in Fort Lauderdale, FL. For a physician referral, call 954-776-9517.

Cancer Patients Who Develop Brain Tumors

  • Posted Nov 06, 2014
  • Ali Jourabchi Ghods, MD

Brain Image from Medline Plus Medical EncyclopediaCerebral metastases are the most common intracranial tumor in adults. Studies have shown that 20-40% of cancer patients will develop cerebral metastases during their disease course. With the combined enhanced detection modalities and new cancer therapies, the life expectancy of patients with cancer is increasing, leading to an increase in expectance of brain metastases. This makes the treatment of cerebral metastases an important consideration in modern cancer therapy.

Historically, cerebral metastases were managed with palliative therapy and were considered the end stage of a patient’s disease, with a prognosis of less than a month. This improved with the introduction of corticosteroid therapy in the 1960s, followed later by the addition of whole brain radiation therapy (WBRT).

Currently, the life expectancy of patients with brain metastases can be dramatically increased with both a combination of surgery and radiation, whether stereotactic radiosurgery (SRS) or WBRT. Corticosteroid therapy is important in the treatment of symptomatic metastases but has significant side effects. Surgery alleviates the need for corticosteroid therapy, reducing the complications from steroid use (i.e. Infection, psychosis, myopathy, intestinal bleeding, elevated sugar and blood pressure). Therefore, surgery for cerebral metastases can have a profound impact on both life expectancy and quality of life.

At the Holy Cross Neuroscience Institute, our multidisciplinary group of expert staff (neurosurgeons, oncologists, radiation oncologists, pathologists and radiologists) determines the best treatment option for patients afflicted with such tumors. Not only do we treat the disease, but we spend time tailoring treatment best suited on an individual basis, knowing not every case is the same. We have expanded our team in order to treat patients in the community and all of Broward and nearby counties. In doing so, we hope to make it easier on patients and families in the community who would otherwise need to commute long distances to other hospitals in order to receive treatment. Our goal is to make a difference and to give a longer and more meaningful quality of life to both the patient and their family.

Dr. Ghods is a neurosurgeon who specializes in brain tumors, and he practices in Fort Lauderdale, FL. For a physician referral, call 954-776-9517.


About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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