Marjolin’s Ulcer

Marjolin’s ulcer is a malignant tumor that usually develops into squamous cell sarcoma inside of an osteomyelitis sinus tract.

Fungating soft tissue mass that increases in size and has a foul smell in addition to x-rays that show chronic osteomyelitis that may indicate malignant transformation. It usually takes a long time to develop (about 20 – 30 years).

This tumor usually occurs in the lower extremity and can occur in association with burns, decubitus ulcer and venous ulcer. The skin lesion appears more aggressive with more metastasis (it also can spread to the lymph nodes). There is more recurrence than other types of skin cancers and it is associated with a high mortality rate.

The treatment is usually an amputation. Preservation of the extremity function through a wide resection may not be possible.

Difference between Marjolin’s ulcer and Mandura foot:

Majorlin’s ulcer is a malignant slow growing squamous cell carcinoma that usually develops inside of an osteomyelitis sinus tract. Mandura foot is localized swelling with multiple discharging sinuses (usually fungus). The discharge is grain filled or granular.

Creating Sustainable Balance Among Your Team

Imagine your organization resembles a sailing boat. You will see a lot of good days, but some bad days. On the good days, there is calm weather, sunshine, smooth sailing, and peaceful enjoyment of nature. On the bad days, there is cloudy weather, rough waters, and sometime you will face a hurricane.

On this boat there are three types of people:

1. Paddler (30% of people): Engaged – Meant to keep the boat moving forward, working above and beyond with a sense of purpose. These are the BEST assets to your organization! They are creative and motivated to help organizations succeed. And they are proud of the contribution their organization makes to the community.
2. Passenger (50% of people): Disengaged – Neutral, they think situations don’t affect them. They are not involved at all. There are here doing their job or doing the bare minimum.
3. Boat Sinker (20% of people): Actively Disengaged – They are the biggest threats to the organization. They often use negativity and pointing fingers to aid in tearing an organization apart.

Leaders must confront the people who are trying to sink the boat. Either they must paddle or get off the boat.

Which type are you? Are you a paddler, a passenger, or are you trying to sink the boat?

Acne Explained

Acne is a folliculitis with acute and chronic inflammation caused by the bacteria propionibacterium acne gram positive bacilli that loves fatty acids of the sebaceous glands. The P-acne bacteria proliferates, setting inflammation in the follicle and when the follicle becomes blocked, the bacteria proliferate even more.

The skin surface has pores which are openings to the follicles. The follicle is under the skin surface. Under the skin surface, the sebaceous glands secrete sebum into the follicle. The oil travels up into the skin through the pores. The secreted oil lubricates the skin and hair. The hair follicle cells produce keratin which is dead skin material that joins the oil through the pores.

Bacteria can also be found within the follicle. Oil, keratin and bacteria are the three elements that flow out of the pore opening. This material is thick and sometimes can act as a glue. If the pore opening becomes blocked, then the acne will start. The pores can become blocked by skin irritation, make-up, cream, or even by touching or squeezing the skin. When the pores are blocked, the oil, keratin and bacteria cannot get out of the skin.

Pressure within the pore begins to build up and make the follicle expand like a balloon. It becomes a pocket full of thick, dirty, undesirable material. The follicle walls stretch and then tear, leaking fluid into the surrounding tissues. Inflammatory cells are attracted to the follicle material and the skin inflammation starts. The follicle will try to repair itself by adding and shedding more keratin and this increases the content of the follicle itself. The pressure builds up and will cause the follicle to burse causing a wider area of inflammation and red pimples on the skin, called acne.

Acne starts around the time of puberty. Before puberty, the oil glands make very little oil. At puberty, the hormones stimulate the sebaceous glands (oil glands) to produce more oil. Some people produce more oil than others, usually due to genetics. Some people produce 10 times more oil than other individuals. A lot of material tried to get out through a small pore. The patient becomes acne prone. The trapped sebum allows bacteria to grow and plus the follicle. This forms the primary acne region called comendo.

Acne can be a white head, where the sebum and bacteria stay below the skin surface. Acne can also appear as a black head where the trapped material goes through a partially open pore and then turns black due to melanin that oxidizes.

In summary, there is a lot of oily material which is sebum. Pores are small and a lot of dead skin cells are shed inside the pore along with a lot of bacteria. Bacteria love the oil that is produced by the sebaceous glands and they feed on it. More oil is produced after puberty. The bacteria enjoy the oil and multiply. As the follicle becomes filled with the undesirable material, the follicle expands and bursts. The material goes beyond the area of the follicle and attracts inflammatory cells.

Running Injuries

There are three general causes of running related injuries: anatomic factors, shoes and running surface, and training errors.

Anatomical Factors

There are many different anatomical factors that may cause running injuries including leg length discrepancies, femoral neck anteversion, asymmetrical muscle inflexibility or weakness, genu valgum, genu varum, genu recurvatum, excessive Q angle, patella alta, tibial torsion, tibial varus, lower leg-heel or heel- forefoot malalignment, pes cavus or planus, structural toe abnormalities and bunions.

Leg length discrepancies are a variation in limb length may be causes by a previous injury to a bone in the leg or arthritis.

A femoral neck anteversion is a developmental abnormality causing abnormal rotation of the femoral neck. With femoral neck anteversion, the femoral neck tilts forward in respect to the rest of the femur causing the lower extremity to rotate internally. Too much femoral anteversion and the toes will turn in.

Asymmetrical muscle inflexibility or weakness is a condition that distributes abnormal and uneven forces to the body creating uneven stresses across the muscle groups and joints.

Genu valgum is also known as “knock knee”. Genu Varum is known as “bow leg”. Genu recurvatum is a deformity in the knee joint where the knee bends backwards at the tibiofemoral joint.

An excessive Q angle is one that is greater than 15°. The presence of an excessive Q angle causes the knee cap to track out of alignment and degeneration of the cartilage behind the knee cap will occur due to increases stresses resulting in pain around the knee cap.

Patella Alta occurs when the knee cap is in an “alta” position; it sits above the trochlear groove and is less stable. The patella tendon that connects the knee cap to the tibia is longer than normal.

Tibial Torsion is the inward twisting of the tibia causing the feet to turn inward. This is commonly referred to as having a “pigeon-toed” appearance. Tibial varus is a curvature of the tibia inwards from the proximal to distal end. It causes problems of the structures around the knee.

Lower leg – heel or heel – forefoot malalignment causes distortions in the knee that may causes the lower leg bones to be off center on the heel of the foot.

Pes cavus is a high arch that is raised more than normal and distinctly hollowing during weight bearing.

Pes Planus is a common deformity in adults that is also known as “flat foot”. The entire sole of the foot will come into complete or nearly complete contact with the ground.

Structural Toe Abnormalities such as Morton’s neuroma. Morton’s neuroma is an enlargement and inflammation of a portion of the plantar digital nerve. It is usually located in the third web space between the metatarsal heads which is felt in the front of the foot, extending to the toes.

Bunions (hallux valgus) can be a big problem with shoe wear.

Shoes and Running Surface

Wearing the proper shoes that are comfortable and provide shock absorbency is important. Old, worn out, uncomfortable shoes may cause running injuries. Attention should be given to the climate surface and terrain to avoid running related injuries.

Training Errors

Consideration should be given to using the appropriate equipment and the progression of workouts in order to avoid injuries. Common training mistakes include wearing the wrong clothing/shoes, not drinking enough fluids, bad body form, and lack of preparation.

The most common running problems are over striding and too much running.