DEAR MAYO CLINIC: I've seen emergency defibrillators in public places, but I've also heard that some people need to wear them or have them implanted for heart rhythm problems. Can you explain the differences? 

ANSWER: Pacemakers and defibrillators are devices that help manage heart rhythm problems, but they work differently. 

A pacemaker helps the heart when the rhythm is too slow or irregular. A defibrillator is a specialized pacemaker designed to treat life-threatening heart rhythms that are dangerously fast or chaotic. It acts by shocking the heart out of a dangerous rhythm. 

Sometimes people unexpectedly have an irregular heartbeat that can cause sudden cardiac death or unconsciousness. During this emergency situation, the heart stops or quivers uselessly and is unable to pump in a coordinated way.   

That's when an automated external defibrillator (AED) can be lifesaving. These are the portable devices you see in airports, schools, gyms and other public places. An AED analyzes a person's heart rhythm during sudden cardiac arrest. If it detects a dangerous rhythm, it delivers an electrical shock to help the heart return to a normal rhythm.  

While people who take CPR courses learn how to use an AED, the devices also provide simple step-by-step instructions, including written, picture and voice prompts, so that a bystander can use one in an emergency.  

Defibrillators also can be worn or implanted. In general, they are used for people who are at higher risk of dangerous heart rhythms, including: 

• Those with heart conditions, such as a weakened heart muscle (also called cardiomyopathy), low pumping function or a history of heart attack. 
• Those born with electrical abnormalities of the heart, called channelopathies, or other inherited heart conditions. These can sometimes affect younger people, including athletes, and may cause fainting, sudden cardiac arrest or sudden cardiac death.  

A wearable defibrillator looks like a vest and is worn under clothing. It continuously monitors the heart rhythm and can deliver a shock if it detects a life-threatening rhythm. It's usually worn temporarily, often while a care team is deciding whether a person needs a permanent, implanted device or while the heart is recovering.  

An implantable cardioverter-defibrillator (ICD) is a permanent device placed inside the body. It monitors the heart rhythm and can deliver treatment if a dangerous rhythm occurs. Some ICDs are placed under the skin in the chest, with one or more wires, called leads, connected to the heart.  

Recovery after ICD placement usually takes about four to six weeks. During that time, patients may need to limit certain arm movements, especially on the side where the device was placed, and watch for signs of infection or increasing pain around the incision.  

After recovery, most people return to their usual daily activities. However, they should avoid strong magnetic fields and certain activities, such as arc welding, unless their care team says it's safe. 

Most patients aren't aware of their defibrillator unless it delivers treatment. If a person is unconscious when a shock occurs, they usually don't feel it. If they're awake, the shock may feel like a sudden jolt or kick in the chest. It can be startling, but it's meant to save a life. In some cases, people may not feel the shock at all, and the event is only found later during a device check. 

Anyone who feels a shock from their defibrillator, or is notified by their healthcare team that a shock occurred, should contact their care team for further evaluation. The device may need to be checked, and medications or other parts of the treatment plan may need to be adjusted. 

There's another type of device therapy called cardiac resynchronization therapy (CRT), which may include features of a pacemaker or defibrillator. It's used for some people with moderate to severe heart failure whose lower heart chambers don’t beat in a coordinated way. 

When the heart’s pumping chambers are out of sync, the heart may not pump blood as efficiently. CRT helps coordinate the timing of the heartbeat. 

As with implanted pacemakers or defibrillators, CRT implantation requires a minor surgical procedure to place a device in the chest, and the recovery and post-procedure care are similar. There are two main types: 

• Cardiac resynchronization therapy with a pacemaker (CRT-P). This device sends electrical signals to help the lower chambers of the heart beat together. 
• Cardiac resynchronization therapy with a defibrillator (CRT-D). This device combines resynchronization pacing with defibrillator protection. It may be recommended for people with heart failure who also are at risk for sudden cardiac death. 

Defibrillators, whether they're used in public places, worn temporarily or implanted permanently, are designed to protect people from dangerous heart rhythms. They can be lifesaving, helping people live more safely and confidently. 

Divya Korpu, M.B.B.S., Cardiology, Mayo Clinic Health System, Eau Claire, Wisconsin 

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DEAR MAYO CLINIC: My back pain keeps getting worse. I've tried all the nonsurgical options, but is it time to consider surgery? 

ANSWER: It might be. The back is a highly complex part of the human body with several potential sources of pain — bones, joints, muscles and nerves.  

Joints: On the back of each spinal vertebra is a pair of facet joints that allow you to bend and twist. These two facet joints, together with the disc, enable the bones of the spine to move. Lower in the back is the sacroiliac joint, which connects the spine to the pelvis. As with any joint, these can be affected by arthritis and injury. The discs, which provide cushioning between the vertebrae, can slip out of place, allowing the bones to rub together. 

Muscles: An intricate muscle structure supports the spine. Strains, overuse and underuse can weaken and damage these muscles. 

Nerves: The spinal cord, which is a bundle of nerves, runs through the spine, ending where the mid back and lower back connect — about at your belly button. From there, nerve roots branch to each leg, providing function to your legs. Anywhere along the spine, but especially in the lower back, the nerves can become compressed. It's radiating leg pain that frequently drives patients to seek relief through surgery. 

The first step in finding back pain relief is to be assessed by a healthcare professional, who, as part of the examination, will check your ability to sit, stand, walk and lift your legs. You also may undergo some imaging. This assessment will help your clinician develop a treatment plan.  

Nonsurgical pain-relief options include: 

• Physical therapy. A physical therapist can teach you exercises to increase flexibility, strengthen back and abdominal muscles, and improve posture. Building these exercises into your daily routine can help prevent pain from returning. The therapist also can show you how to modify the exercises and your movement during a back pain episode.  

• Ice/heat. The use of an ice pack or heating pad can help relieve pain from muscle tension and spasms. 

• Pain relievers. These include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil); acetaminophen(Tylenol); topical creams and patches that deliver substances through the skin; medicines containing opioids, such as oxycodone or hydrocodone (rarely used); and some antidepressants, including duloxetine (Cymbalta).  

• Muscle relaxants. If mild to moderate back pain doesn't improve with ice, heat or pain relievers, a muscle relaxant is another option.  

• Injections. If other measures don't relieve pain that radiates down the leg, an injection of cortisone plus a numbing medicine might help. 

• Other treatments. Yoga, massage, chiropractic adjustments and acupuncture also may bring relief. 

When these measures are no longer effective, patients typically seek out surgical options. For the best outcomes, it's essential that the surgical procedure matches the problem that needs to be addressed. These can include neurological compression, instability or spine deformity issues.  

A consultation with a surgeon usually includes an examination and imaging to pinpoint the problem, followed by a discussion of what surgical approach will provide the greatest benefit. After the consultation, you may want to talk over your options with family and friends or seek a second opinion to ensure you're comfortable with the plan. 

Before surgery, you'll be thoroughly assessed to determine if you're physically ready for the procedure. This will include evaluating your bone health and ensuring that any medical conditions are stable or optimized. 

The surgery depends entirely on what is needed to correct the problem. Some surgeries are relatively simple, while others may be quite complex. 

Recovery and healing depend on how extensive the surgery was. For instance, a herniated disc may require only a small incision, followed by a short period of limited activity. Recovery from a more involved surgery requiring a large incision may take months. 

However, most people fall somewhere in the middle of this spectrum. They generally feel pretty good within six to 12 weeks, although full recovery typically takes six to 12 months. 

Once a person has recovered, the key is developing a lifestyle that helps prevent back issues from returning. These include building good core muscle strength, increasing mobility, staying active, not smoking, and maintaining a healthy weight and diet. 

Being active and maintaining good core strength not only are essential to recovery from surgery, but they also are key to preventing back pain. 

Mel Helgeson, M.D., Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota  

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DEAR MAYO CLINIC: My neighbor is in his 60s and has spent years competing in marathons and long-distance cycling events. Despite being in excellent shape, he recently learned that he has a high coronary calcium score. I thought endurance athletes were less likely to develop heart disease? I'm in my 50s, run regularly and am training for a half-marathon. Should I be worried about this? 

ANSWER: It's understandable to wonder how this can happen. Regular exercise is one of the best things you can do for your heart. It lowers the risk of heart disease, improves blood pressure, helps control weight and supports overall health. 

However, being physically fit doesn’t make someone immune to heart disease. A coronary calcium score can help identify people who may be at increased risk despite having an active lifestyle. 

A coronary calcium score measures calcium buildup in the arteries that supply blood to the heart. The test uses a CT scan to identify calcified plaque, which is a marker of atherosclerosis, also known as hardening of the arteries. 

The score helps estimate a person's future risk of heart disease and provides additional information about overall cardiovascular health. In general, a score of 0 is associated with a lower likelihood of future heart disease than higher scores. Scores above 100 suggest a higher risk, while scores above 300 may lead healthcare professionals to recommend treatment or other steps to lower that risk. 

It's important to understand what the test does and does not show. A high score doesn’t mean a heart attack is about to happen, nor does it automatically mean an artery is blocked. Some people have elevated calcium scores but still have enough blood flowing to the heart and may not experience any symptoms. Instead, the score can help guide decisions about prevention, treatment and follow-up care. 

Researchers continue to study why some older endurance athletes have higher coronary calcium scores than people who participate in moderate levels of exercise. While this finding has been observed in studies, more work is needed to understand why it occurs and what it means for long-term cardiovascular health. 

At the same time, people who regularly participate in endurance activities generally have lower rates of heart-related problems than those who are sedentary and tend to have better overall cardiovascular fitness. Even so, some highly active people still develop elevated calcium scores despite years of regular exercise. 

A high calcium score shouldn’t be viewed as a reason to stop exercising. Instead, it should prompt a discussion with a healthcare professional about your overall risk for heart disease. 

The score is only one piece of the puzzle. Other important factors include: 

• High cholesterol. 

• High blood pressure. 

• Diabetes. 

• Obesity. 

• Smoking history. 

• Family history of heart disease. 

• Dietary habits. 

Many of these risk factors can be managed through lifestyle changes, medications or both. Addressing them can help lower overall cardiovascular risk and support long-term heart health. 

Depending on your symptoms and other risk factors, your healthcare team may recommend additional testing, such as a cardiac stress test. 

If you notice any of the following symptoms during physical activity, even if you otherwise feel healthy and active, talk with your healthcare team: 

• Chest pain or pressure. 

• Unusual shortness of breath. 

• Symptoms that seem unusual for your normal level of activity. 

The most important takeaway is simple: Don't stop exercising. Instead, use the results as an opportunity to better understand your heart health and work with your healthcare team to address any modifiable risk factors. Understanding your overall risk for heart disease and taking steps to lower it can help you continue exercising safely for years to come. 

Gurpreet Singh, M.D., Cardiology, Mayo Clinic Health System, Eau Claire, Wisconsin 

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DEAR MAYO CLINIC: I have a benign lesion on my liver that needs to be removed. My surgeon said he would use robotic-assisted surgery. Can you tell me more about that? 

ANSWER: Yours is a common question. When people first hear "robotic surgery," they often think of a robot on autopilot doing the procedure. However, that couldn't be further from the truth. The robotic arm is a tool driven by the surgeon, following maps created from preoperative imaging. 

Robotic technology is being used during abdominal surgery for benign and cancerous tumors in the liver, pancreas, colon and rectum, as well as gallbladder removal. 

Your liver helps digest food, rids the body of waste products and makes clotting factors that keep blood flowing well, as well as performs other tasks. Parasites, diseases, viruses, infections, injury, cancer, alcohol use, obesity and inherited factors can all damage your liver. 

Any of these causes may lead to surgery, including the use of robotic technology, which can benefit patients in several ways. 

With open surgery, an incision would be made from the breastbone to your navel or sometimes with a right-angle turn like a hockey stick. The benefits of robotic-assisted surgery include:  

• Smaller incisions, which lead to less blood loss and stress on the body. 

• Reduced postoperative pain.  

• A lower risk of surgical complications.  

In general, with less pain, recovery is faster, and the risk of complications such as pneumonia or intestinal temporary paralysis, which can occur in up to 20% of all open abdominal surgeries, is less because patients are up and moving sooner. 

Prior to surgery, patients undergo a CT scan and MRI, which will provide the imaging needed for your surgeon and for mapping. If surgery is due to cancer, this imaging may have been done periodically to watch for changes or as part of the patient's treatment. 

The surgery includes a team of professionals who administer anesthesia, fluids and blood, if needed, and monitor the heart and blood pressure. Patients also have a urinary catheter inserted most of the time. 

Once the patient is under anesthesia, the surgeon makes multiple incisions slightly less than 1/2 inch long and one incision about 2 inches long, if needed, to remove larger specimens from the abdomen. Using the robot's arms as extensions of their hands, the surgeon uses a variety of tools, including those to make incisions, apply clips, seal structures, sew sutures and remove tissue from the surgical site. Tiny cameras deliver magnified views to allow the surgeon to see the whole process in detail. 

Once the surgery is complete, the incision typically is closed with absorbable sutures and glue so that stitches don't have to be removed postoperatively. No bandages are needed, and patients can shower 48 hours after the surgery. 

Some surgeries require the removal of a portion of the liver. Up to 70% of a healthy liver can be removed and still function effectively. However, if a liver has been damaged by chemotherapy and other causes, as little as 50% may be removed. It's a myth that the liver regenerates. However, the remaining liver segment will grow large enough to function and compensate for the loss. 

While robotic-assisted surgery is minimally invasive, it's still invasive. After surgery, patients are watched for complications from bleeding and anesthesia, as well as any effects on their hearts and lungs, similar to other general surgical procedures.  

In liver surgery, there's also a small risk of bile leakage. Bile is the green fluid produced by the liver and channeled to the small intestine to aid with digestion. Leaks typically can be spotted during surgery, but if one develops, it can be corrected with endoscopic procedures or radiological interventions. 

Opportunities for using robotic technology in liver and abdominal surgeries are expanding. Robotic technology opens the door to training more physicians in its use for surgeries ranging from less complex to more complex. As more surgeons become proficient in its use, the pool of patients who can undergo surgery to benefit their health, recovery and general well-being also widens. 

Guido Fiorentini, M.D., Ph.D., Surgery and Surgical Oncology, Mayo Clinic Health System, Eau Claire, Wisconsin

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DEAR MAYO CLINIC: Our teenagers are both student athletes and active in their sports year-round. I'm concerned about injuries that could sideline them. What should we watch for?

ANSWER: As the school year ends, summer sports heat up for students and adults alike. Summer may be a prime season for a sport, such as baseball or running, but athletes of all types also may be on a traveling team, heading to a sports camp or just honing their skills with off-season practices.

No matter an athlete's age, they need to be aware of and condition their body to prevent injuries that can put their sport on hold. Here are several to watch for:

Heat-related injuries. When it's hot and humid, proper hydration is essential. Signs of overheating include not sweating, feeling extremely thirsty, becoming dizzy, experiencing a headache or vision changes. These symptoms call for immediate attention. All athletes should hydrate before, during and after their activity. Water is best, as are drinks that replenish electrolytes lost through perspiration.

Sprains and strains. These common injuries can affect ankles, knees, hips and shoulders. However, they aren't traumatic injuries like fractures or a complete ligament tear, and they tend not to require long-term recovery.

Tendons attach muscles to bones, while ligaments attach bones to bones. A sprain is the stretching or partial tearing of the fibers in a ligament. A muscle or tendon strain may result from overuse, leading to inflammation. Both are treated by modifying activity, rest, icing, and taking over-the-counter pain and anti-inflammation medications. Physical therapy may be needed to rebuild strength and range of motion.

Fractures. A fracture is a broken bone. Fractures often occur during falls, such as when skateboarding, or from collisions with other players or objects. Fractures can be cracks or complete breaks that may or may not require surgery. Treatment and recovery depend on the severity of the injury. Athletes should plan to be in recovery for at least 6 weeks.

Overuse injuries. With the emphasis on early sports specialization, young athletes often spend more time practicing or competing, increasing the risk of injury. This injury risk is especially true for young athletes who are still skeletally immature. That means they still have open growth plates in their bones, making them susceptible to injury, particularly from repetitive motion.

Athletes understand that repetitive motion is the way to improve. However, if a young athlete is pitching every day or repeatedly practicing a volleyball serve, they can overuse a single part of their body. This can lead to inflammation or even damage those areas. One indication of overuse is pain after a game or practice that takes longer to resolve, increasing recovery time.

Safeguards such as pitch counts, which limit the number of pitches a player throws during a game, and built-in rest days are important to preventing overuse injuries.

Another way to avoid overuse injuries —and burnout — is cross-training. For instance, a hockey player may add swimming to their routine, a runner may add weight training, or a soccer player may shoot hoops with friends. This allows an athlete to use different muscles and movements to build strength, flexibility and coordination, while also giving them a mental break.

Concussion. A concussion is a mild traumatic brain injury that affects brain function. Effects are often short-term and can include headaches and trouble with concentration, memory, balance, mood and sleep. Concussions can happen in any sport, not just those in which players intentionally run into each other, such as football or hockey.

If a player experiences dizziness, headache or nausea after an incident during a game or practice, they shouldn't shrug it off — they should step out of the game and tell a coach or parent. Today, most coaches are trained in concussion and return-to-play protocols developed for most sports. Athletes, parents and coaches should take concussions seriously to prevent further injury or long-term symptoms.

Injuries in older athletes. Older athletes returning to a sport or trying a new one are susceptible to the same injuries as young athletes. However, osteoarthritis, or the wearing down of the cushioning cartilage in joints, increases with age. This can lead to pain, swelling and a decrease in range of mobility. Once again, cross-training is key, no matter your age.

All athletes can reduce the risk of injury by getting plenty of sleep, developing healthy eating habits, hydrating and warming up properly before any sports activity.

For parents, if your child finds a sport they enjoy and are passionate about, encourage them, but don't let it become a "job." As a former professional athlete, I advise that, first and foremost, sports should be fun.

Michael Stuart, M.D., Orthopedics & Orthopedic Surgery, Mayo Clinic Health System, Owatonna, Minnesota

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DEAR MAYO CLINIC: My cousin, who's in his late 20s, was recently diagnosed with testicular cancer. I didn't know this is something younger guys need to worry about. Can you fill me in?

ANSWER: Testicular cancer isn't common — about 9,800 men are diagnosed each year and 1 in 250 may be diagnosed in their lifetime — but it most commonly affects men between the ages of 15 and 45. It's not something to worry about; however, it is something to be aware of. In addition to your age, you're at a higher risk of testicular cancer if you:

• Have an undescended testicle.
• Have a family history of testicular cancer.
• Are white.

It's not clear what causes testicular cancer, which typically affects just one testicle. But it starts when something changes the DNA of the testicular cells, causing them to grow and multiply quickly, forming a tumor. Nearly all testicular cancers begin in the germ cells, which make sperm.

Signs of testicular cancer include:

• A lump, bump or swelling in either testicle.
• A feeling of heaviness in the scrotum, which is the loose bag of skin beneath the penis and holds the testicles.
• A dull ache in the lower belly or groin.
• Sudden swelling in the scrotum.
• Pain or discomfort in the scrotum or a testicle.
• Enlargement or tenderness of breast tissue.
• Back pain.

Testicular cancer is highly treatable, even if it spreads to other parts of the body. Treatments include surgery and chemotherapy.

There isn't a screening test for testicular cancer, although healthcare professionals may recommend a self-exam, just as women do breast self-exams. Your clinician can show you how to do it.

However, there's no research to show that self-exams lower the risk of dying from testicular cancer, since it's highly curable even at late stages. But a self-exam will help you become more familiar with the feel of your testicles and alert you to any changes.

If you're experiencing pain or swelling or have felt a lump or bump in your testicle that hasn't gone away in two weeks, it's time to consult with your healthcare professional.

At your appointment, they will examine your scrotum, feel the testicles and may order an ultrasound. These images can help with diagnosis. If cancer is suspected, a blood test can detect the proteins made by cancer cells. Having them in your blood doesn't mean you have cancer, but higher levels provide your healthcare team with clues to what is going on in your body.

From there, you may need surgery to remove the testicle and have it tested for cancer. If the cancer hasn't spread beyond the testicle, this may be the only treatment you'll need. If there's concern that it's spread to some lymph nodes, those nodes also will be removed and tested.

Depending on the findings, your oncology team will put together a treatment plan, which may include chemotherapy, radiation or immunotherapy. Because these treatments may affect fertility, you'll want to discuss options with your team for preserving sperm.

Following treatment, your care team typically will follow your progress for five years.

Remember, testicular cancer is highly curable. But early detection can make a difference. That's why it's important to schedule regular physical exams. At those exams, bring up any concerns you might have about symptoms and be prepared to provide details about them to your clinician. These may include:

• When did they begin?
• Are they continuous or occasional?
• How severe are they?
• Does anything improve them or make them worse?

If at any time you have concerns about symptoms, don't ignore them. Make an appointment to see your primary care healthcare clinician. Being proactive about your health is one of the most important things you can do for your overall well-being.

Mohammed Solaiman, M.D., Family Medicine/Primary Care, Mayo Clinic Health System, Mankato, Minnesota

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DEAR MAYO CLINIC: Since I turned 40, my clinic has been sending me a slew of reminders about men's health screenings. Are they really necessary?

ANSWER: Yes! Blocking out some time for these important health screenings is one of the most important things you can do for yourself.

Historically, men have been hesitant to seek medical attention when something seems wrong with their health. Also, they aren't as likely as women to have preventive screenings and checkups. This is a problem because early detection is the best way to effectively treat and manage a medical issue. 

If you're reluctant about seeing a healthcare professional, rethink your hesitation. Delaying or avoiding a checkup or screening could lead to a treatable situation turning deadly. Here are the exams and screenings to add to your to-do list for a healthy life.

Regular physical exams. Males older than 50 should have a yearly physical exam, and those younger than 50 should have a physical exam every three to five years.

A regular exam isn't just about screenings. It can validate that you're healthy, and it's your chance to ask your healthcare professional about issues or symptoms that are bothering you. For instance, if you're having issues with erectile dysfunction, this could be a symptom of coronary artery disease. The sooner it's addressed, the better for your overall health.

Vaccines are also essential to prevent infectious diseases. Vaccinations for men are administered at different intervals throughout adulthood. 

Health isn't only physical, so talk with your healthcare team about your mental and emotional health. If you're struggling in those areas, effective help is available. 

While you may only need to get some screenings once, such as HIV and hepatitis C, you should have screenings for certain conditions and cancers regularly. Keep in mind that earlier and more regular screening is recommended for all these conditions if you're at higher risk.

Abdominal aortic aneurysm. Because the aorta is the body's main supplier of blood, a ruptured abdominal aortic aneurysm can cause life-threatening bleeding. Men 65 to 75 who have used tobacco products should undergo a one-time ultrasound screening. Those over 60 with a family history of abdominal aortic aneurysm should consider repeat screening at regular intervals. 

Colon cancer. Experts advise that most adults at average risk begin colorectal cancer screening at age 45. Several screening tests are available, including stool-based tests and exams that look directly at the colon. Each test has different benefits, risks and testing schedules. But if you experience symptoms, don't wait to get screened.

Diabetes. If you're older than 35, you should have an initial blood sugar test. No matter your age, if you have a body mass index above 25 and additional risk factors, such as high blood pressure or a family member with diabetes, you should be screened. Type 2 diabetes and prediabetes symptoms can develop slowly and may not be noticeable. 

Blood pressure. A blood pressure reading is a good indication of many aspects of your health. High blood pressure can lead to other physical problems, especially heart-related conditions. Beginning at age 18, you should have your blood pressure checked at least every two years, and every year if you're at risk for high blood pressure and after you turn 40.  

Cholesterol. Like high blood pressure, high cholesterol may pose serious risks to your health and well-being. Starting at age 17, men at average risk for heart disease should have a cholesterol screening every four to six years and more frequently over age 40. If you have conditions such as high blood pressure and/or diabetes, a family history of high cholesterol or heart attacks, smoke, eat a poor diet, are overweight, have diabetes or are physically inactive, you should be tested more often.

Prostate cancer. Around age 50, talk with your healthcare professional about prostate cancer screening. Together, you can decide whether screening is right for you. If you're Black, have a family history of prostate cancer or have other risk factors, consider screening earlier.

Lung cancer. If you have an increased risk of lung cancer, consider yearly screening, which uses low-dose CT scans. If you smoked heavily for many years, your healthcare professional may recommend lung cancer screening at age 50 and older. Screening is also offered to people who have quit smoking in the past 15 years. Discuss your lung cancer risk with your healthcare professional to decide if lung cancer screening is right for you.

Do yourself and your family a favor by protecting your health with regular checkups and screenings. Add to that exercise and managing your body weight, mental health and stress, all of which are part of keeping you healthy.

Mohammed Solaiman, M.D., Family Medicine, Mayo Clinic Health System, Mankato, Minnesota

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DEAR MAYO CLINIC: My nephew is in his 20s and has been complaining about ongoing hip pain, especially after working out. When it didn’t improve, he saw an orthopedic specialist and was diagnosed with hip impingement. What is that?

ANSWER: Hip impingement, also called femoroacetabular impingement, is a condition that often affects young, active adults. It occurs when the shape of the hip joint causes the ball and socket to pinch during movement. Over time, that can lead to pain, stiffness and wear in the joint.

Hip impingement exists on a spectrum. Some people have changes in the shape of the hip and never develop symptoms. Others develop pain that begins to affect exercise, work or everyday activities.

The hip is a ball-and-socket joint. In some people, the socket may develop differently, or extra bone may form where the ball and neck of the femur meet. That extra bone on the femur is often called a cam lesion. These shape changes can cause the bones to come into contact earlier than they should during movement, especially when the hip is bent deeply during sitting, squatting or sports. This can lead to pain and reduced range of motion.

Hip impingement is much more recognized today. The condition became better understood in the early 2000s, when specialists began linking some cases of hip pain and early arthritis to structural differences in the hip joint. Young adults also may be active longer, which can make symptoms more noticeable. However, not everyone with hip impingement has symptoms.

The most common symptom is groin pain. Some people also describe pain that wraps around the side of the hip in a C-shaped pattern. Symptoms often become worse with prolonged sitting, long car rides or activities that involve deep hip flexion, such as deep squats or stepping onto a high surface.

Occasional pain that goes away may not need immediate evaluation. However, you should seek medical care if hip pain persists for weeks or months, begins to affect daily life, or prevents participation in activities you enjoy.

Sports and activities that involve deep hip bending, agility and pivoting can make symptoms more likely. This includes hockey, rowing, soccer, hurdles and some forms of dance, especially ballet.

Typically, hip impingement isn't something people are born with; the shape of the hip develops over time. The socket reaches its final shape relatively early in life. Changes on the femur side of the joint, including cam lesions, are thought to develop during adolescence, especially in active teens.

Diagnosis often starts with the symptoms a person describes. Groin pain, pain with sitting, and a pinching sensation during activity can all point toward hip impingement. A physical exam also is important, since many people have reduced motion when the knee is brought up toward the chest. X-rays help evaluate the shape of the hip. In some cases, an MRI is used to examine the cushioning cartilage, such as the labrum, more closely, especially if surgery is being considered.

The first line of treatment often is physical therapy to strengthen the core, lower back and muscles around the hip. Activity changes and anti-inflammatory medications also may help. It’s important that therapy specifically targets hip impingement, since some exercises may worsen symptoms.

If symptoms continue and begin to affect quality of life, surgery may be considered. The most common procedure is hip arthroscopy, which uses small instruments and a camera to repair the labrum and reshape areas of bone. Recovery takes time, with crutches often needed for four to six weeks, followed by a gradual return to activity. Most people improve within three to four months, although returning to higher-level sports may take closer to six months.

If left untreated, outcomes for hip impingement depend on the severity of the condition.  In some people, it may raise the risk of arthritis later in life. In others, symptoms may stay mild or manageable. Not every person with hip impingement will need surgery, and treatment decisions should be based on symptoms and how much the condition affects daily life.

Hip impingement can be an overlooked cause of ongoing hip pain in young adults, especially in people who are active. It’s often manageable with the right treatment and activity changes. If hip pain keeps coming back or begins to interfere with daily life, it’s worth getting checked rather than assuming it’s just a strain.

Mason Uvodich, M.D., Orthopedics & Orthopedic Surgery, Mayo Clinic Health System, La Crosse and Onalaska, Wisconsin

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DEAR MAYO CLINIC: A friend has had several small skin cancers removed, and that made me wonder if I'm at risk, too. What everyday habits can help reduce my risk of skin cancer?

ANSWER: Whether skies are clear or overcast, your skin is exposed to ultraviolet (UV) radiation from the sun. UVB rays are the primary cause of sunburn, while UVA rays penetrate more deeply, contributing to premature aging, such as fine wrinkles and sunspots. Both forms of UV radiation increase the risk of skin cancer.

A tan is not a sign of health; it's evidence of skin injury. There's no safe way to tan in the sun or with indoor tanning. Fortunately, daily habits can protect your skin and reduce your risk of skin cancer.

Use sunscreen consistently. Choose a broad-spectrum sunscreen that protects against both UVB and UVA rays with an SPF of at least 30. Be aware of the expiration date and replace your sunscreen regularly. Keep it out of the heat and direct sunlight, which can degrade its effectiveness.

Spray sunscreens are typically easier to apply to hairy skin. Makeup also can contain sun-protective ingredients, but it should meet the same minimum standard of a broad-spectrum sunscreen and an SPF of at least 30. Sunscreens may contain organic or inorganic ingredients, or a combination of both.

Inorganic (mineral) sunscreens contain minerals such as titanium dioxide and zinc oxide and provide excellent, broad-spectrum protection. These ingredients tend to be thicker and may leave a whitish residue on your skin.   

Organic (chemical) sunscreen filters are more common and tend to be lighter, easier to spread and less visible on the skin, but they may not have as much UVA protection as mineral options.

The Food and Drug Administration recently announced its proposal to add a new organic sunscreen ingredient, bemotrizinol (BEMT), to its approved list for use in the U.S. BEMT provides protection against both UVA and UVB, and it has low levels of absorption through the skin into the body. This is exciting news because the U.S. doesn't have as many approved filters compared to other countries.

Apply sunscreen whenever you're outdoors — even on cloudy days, when up to 80% of harmful rays penetrate the clouds. When applying sunscreen:

• Don't forget places like the tops of your ears and feet, the back of your neck, and areas where a beard might not be as thick. 
• Reapply sunscreen every two hours.
• Remember to reapply more often with water exposure or sweating because this reduces how long the sunscreen remains effective. Water-resistant sunscreen provides protection for about 40 to 80 minutes. 
• Apply more sunscreen than you think. Most people apply only a quarter to half of the amount needed to reach the advertised SPF on the product label. A simple strategy is to apply a full layer, then repeat to create a "double coat" to ensure adequate coverage. 

Wear photoprotective clothing. Long-sleeved shirts, pants, wide-brimmed hats and sunglasses provide consistent protection without the need for reapplying sunscreen. Not all clothing blocks the same amount of UV rays. Test it by holding it up to the light. If you can see the light through the clothing, you'll know that UV rays can pass through, too.

Many brands now offer lightweight, breathable clothing with built-in ultraviolet protection rated with an ultraviolet protection factor (UPF). For water activities, rash guards offer convenient, reliable sun protection. Tops are available in short- and long-sleeved styles, with or without hoods. 

Avoid intentional tanning. Indoor tanning significantly increases the risk of cancer. Tanning beds emit intense UV radiation and can increase melanoma risk by 20% with just one session. Using indoor tanning before age 35 can increase melanoma risk by 75%. Dermatologists see patients in their 30s with multiple skin cancers and advanced sun damage after extensive tanning bed use in their teens and 20s.

If you want a bronzed glow without the risk of UV rays, sunless tanning products are a safe alternative. Spray tans and lotions containing dihydroxyacetone can create the appearance of tanned skin without UV exposure.

Be mindful of peak sun hours. If you love being outdoors, whether it's hanging at the beach, working in the garden, hiking on a fall day or skiing down a mountain, it's wise to use a combination of sun-protective behaviors, including sunscreen, photoprotective clothing and seeking shade when possible. Consistent sun-protective behaviors will substantially reduce your risk of skin cancer while allowing you to enjoy time outdoors safely.

Steven Nelson, M.D., Dermatology, Mayo Clinic, Phoenix 

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• Mayo Clinic Q&A: Advances in staging and surgical treatment of melanoma 
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DEAR MAYO CLINIC: I'm in my 50s and have begun experiencing nagging back pain. Recently, I saw an orthopedic doctor and was diagnosed with scoliosis. Does this mean I have to have surgery? 

ANSWER: Not necessarily. Scoliosis in adults may require no treatment or be able to be managed without surgery. It all comes down to the severity of symptoms and whether there are accompanying problems, like arthritis or osteoporosis. 

Scoliosis is a change in the normal shape of the spine that leads to sideways or forward curving or twisting. It most often develops in children during their growth spurt just before puberty. Affected children who don't respond to nonoperative measures may undergo surgery to straighten and properly balance the spine. 

In adults, scoliosis may be a remnant of a curvature that began in childhood. More commonly, scoliosis is the result of wear and tear on the spine that comes with aging, usually in combination with another condition that affects the spine, such as arthritis or osteoporosis. Usually, it's these conditions that are causing discomfort. 

Symptoms 

Symptoms of adult scoliosis include low back pain and a stooped posture. Some older adults, despite having significant curves in their spines, may have no symptoms. In other cases, they have symptoms that respond to nonoperative measures such as weight loss, physical therapy, stretching, or maintaining an active, low-impact lifestyle. Both of these scenarios are unlikely to require surgical treatment.   

Many adults seek medical care when symptoms become bothersome or limiting. 

Typically, physical therapy is the first step in treatment. Recommended exercises, along with stretching and walking, may be all that's needed to relieve pain, improve mobility and keep you active.  

If osteoporosis or arthritis is contributing to scoliosis, your healthcare professional will want to address how best to manage your bone health and prevent the curve from getting worse as your bones get softer. 

Treatment options

Treatment may include bone scans to determine the degree of bone loss, weight-bearing exercises to strengthen your bones and medications or infusions that help your body repair and build bone. 

If your pain continues despite nonsurgical treatments or if your scoliosis symptoms become so severe that they limit your mobility or produce a disfiguring deformity, then it's time for you and your healthcare team to discuss surgery. 

For a good surgical outcome, it's not necessary to completely correct the abnormal curves. The goal for adults is a balanced spine — that means your head is positioned directly over your pelvis from front-to-back and side-to-side. This alignment can achieve a high degree of satisfaction and pain relief after surgery. Many patients' symptoms arise from arthritis or pressure on the nerves and can be effectively relieved by removing the pressure, not necessarily by fully correcting any deformity. 

Surgery

One of the most common surgical approaches for scoliosis is spinal fusion. In many cases, spinal bones that are out of alignment account for a significant portion of the deformity. Spinal fusion helps your surgeon realign the bones, improve the curvature of the spine and make the spine more stable. This may be performed alongside a spinal decompression to remove any bone spurs or pressure on the nerves. 

During spinal fusion, your surgeon places bone or a bone-like material in the space between two spinal bones. Metal plates, screws or rods might hold them together so the bones can fuse together and heal as one bone. 

After spinal fusion, you'll be required to stay in the hospital for two to three days. Depending on the location and complexity of your surgery, you may experience some pain and discomfort, which can be controlled with pain medications. 

At some surgical centers, scoliosis surgery can be performed using minimally invasive techniques that shorten recovery times. Regardless of the surgical approach, it can take several months after surgery for the spinal bones to heal and fuse together. During that time, you may need a brace to protect and support your spine. 

In the area where the bones were fused together, spinal mobility is limited. Physical and occupational therapy can teach you ways to sit, stand, bend and walk to improve your mobility and quality of life.  

Although spinal fusion surgery for adults with scoliosis may not eliminate all symptoms, in a high percentage of cases, it can effectively balance the spine, relieve posture symptoms and allow you to get back to doing the activities you enjoy. 

Paul Huddleston, M.D., Orthopedic Surgery/Spine Care, Mayo Clinic Health System, Red Wing, Minnesota, and Mayo Clinic, Rochester, Minnesota  

Related post:

• Tomorrow’s Cure: Shaping a new future for youth with scoliosis

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