Ankle Pain

As summer gives way to fall, we may find ourselves hitting the hiking trails. Many times, these uneven surfaces can lead to foot and ankle issues. Many people have sprained their ankle in the past, and are aware what this feels like. A lateral ankle sprain is an acute twisting of the ankle (often an inversion injury or an inward twisting of the foot and heel as compared to the leg). However, there is another condition which can cause pain on the lateral (outside) part of the foot, which many people will incorrectly refer to as “ankle pain”. I am referring to a pathology know as sinus tarsi syndrome.

The ankle joint consists of three bones, the Tibia, the Fibula, and a bone called the Talus. There are several ligaments working to help support the ankle which are very commonly sprained or ruptured with inversion sprains. However, sometimes there is only a small trauma, or repetitive micro-trauma from uneven surfaces that can affect another joint. The Sinus Tarsi (sometimes referred to as the “eye of the foot due to its appearance on an x-ray) is a very specific part of a joint called the subtalar joint.

Ankle Pain

This is the joint between a bone called the talus and the heel bone (known as the calcaneus). This portion of the joint contains many ligamentous attachments between the talus and calcaneus themselves, and between these two bones and the other bones of the mid-foot. When this joint is injured, there is often nagging pain along the lateral foot or across the ankle joint. Patients will often complain of pain in the morning or after periods of rest. They may find themselves hurting at the beginning or a run or hike, with the pain actually subsiding after getting warmed up. Certain motions like stepping off a curb, or walking up and down steps may cause sharp sudden pain.

Two tendons know as the peroneal tendons border the outside foot and ankle and help invert and evert the foot. When the sinus tarsi of the subtalar joint is painful, these tendons often over act, leading to a tendinitis which can even extend all the way to the lateral calf. Patients may complain of a pulling or stretching pain which extends to the outside calf. Often, when people complain of an “ankle pain” but have a difficult time expressing just how they hurt, direct palpation of the sinus tarsi will recreate the symptoms.

Treatments often include the standard RICE therapy (rest, ice compression, elevation), range of motion exercises (often pretending the big toe is the tip of a pen and tracing the letters of the alphabet in broad motions), oral anti-inflammatory medications, or steroid injections into the sinus tarsi itself. Also, many times supporting the foot with an orthotic is extremely beneficial and/or wearing supportive shoe gear with increased shock absorption.

So the next time you have a lingering “ankle pain” that just doesn’t seem to be getting better, ask your foot care professional about a possible sinus tarsi syndrome.

Lower Back Pain

There is a price that we pay for walking upright, and that is namely lower back pain. About 80% of the adult population has back pain at some point in their lives. The pain varies from mild achiness to disabling, tear-drawing, searing pain. The cause of back pain is often due to weakness of the core musculature and tightness of the muscles along the spine. Also, tightness of the hamstrings can cause back pain or exacerbate the pain. It is very important to keep your abdominal muscles strong and your hamstrings stretched to prevent and even to treat back pain.

Besides the pain, it is important to treat nerve symptoms. If you are having back pain that shoots down your leg, that could be a sign of something much more serious. A herniated disc can actually put pressure on one of your nerves, which will not only cause tremendous pain, but can lead to irreparable damage to the nerve. If you have weakness or tingling down your leg, immediately call an orthopedic specialist and get it checked. Fortunately, most people with a herniated disc do not need surgery. Therapy, anti-inflammatory medication, and walking can often relieve the symptoms. Do not sit or lie down in one position too long as the muscle spasm will just get worse and cause more pain when you try to move.

As with most medical problems, getting the correct diagnosis is important. Back pain has many causes and I have diagnosed people with fractures and cancer who present with just with lower back pain. There are signs on physical exam that help identify where the pain is coming from. An MRI is a great test for identifying herniated discs. Simple x-rays will show fractures and arthritis. CT scans may be helpful as well, but we try and avoid getting them, as there is much higher radiation from this test.

If you have mild back pain, stretch out and walk around. Take Advil or another anti-inflammatory medications and give it a few days. If you don’t get better, the pain gets worse, or you have any nerve symptoms going down your leg, go see you orthopedic specialist.

Rick Weinstein, MD, MBA
Director of Orthopedic Surgery
Westchester Health Associates

Beware! Low Fat May Mean High Sugar

Many of us are constantly searching for the “best” foods to eat. Our grocery stores are filled with hundreds of products “designed” to help us eat healthier. Foods are labeled as low fat, reduced fat, low calorie, low sugar, sugar free, etc. to presumably aid us on our weight loss or healthy eating quests.

Many Americans choose low and reduced fat items thinking these products are good dietary choices that are lower in calories and therefore, healthier than their full fat counterparts. However, research has shown that low fat foods are not necessarily better for you, because many products that are low in fat or reduced in fat are often very high in sugar. In fact, some studies show that these so-called diet foods sometimes have as much as 40% more sugar than the regular versions and can have the same amount or even a higher number of calories! This is because fat supplies the flavor in many foods, and when fat is eliminated, sugar is often substituted to make the food taste good. Salt and other additives are also usually added to enhance flavor, which makes the food even unhealthier and causes additional health risks.

When people eat lower fat foods, they often wind up overeating. Part of this is psychological – people believe they can eat more of a “healthier” food. There is also a scientific basis for overeating products high in sugar. Sugar is a simple carbohydrate and is easily digested and absorbed. This can lead to blood sugar fluctuations and food cravings, which may make it difficult to control caloric intake. Overeating causes fat storage and weight gain. Additionally, sugar causes inflammation in the body and increases the risk of diabetes, heart disease, and high cholesterol.

It is extremely important to decrease the amount of sugar we consume. Last year, The World Health Organization changed its sugar intake recommendations from 10 percent of daily calorie intake to 5 percent, which is about 6 teaspoons, or 25 g, of sugar per day. Sugar is hidden in many processed foods, so it is important to read food labels so that you are aware of what you are eating. Be on the lookout for sucrose, corn syrup, dextrose, high fructose corn syrup, molasses, honey, and malt syrup to name a few.

Consumers should pay careful attention to the amount of calories per serving and the amount of sugar per serving before assuming that low fat or light is synonymous with healthy. The best way to ensure you eat a healthy diet that is low in fat and calories is to avoid processed foods as much as possible. Eat a diet filled with fruits, vegetables, lean protein, and drink plenty of water. This will ensure you receive all the nutrients that you need in a healthy way.

Can’t Control Your Hunger or Cravings?

It Could Be Your “Hunger Hormones!”

Do you find that you’re always thinking about food? Do you have an insatiable appetite? Are you having trouble losing weight despite cutting your calories way down? If so, you may be realizing that successfully achieving weight loss is not as simple as following the classic “calories in-calories out” model. Instead, you need to focus on the hormonal imbalances that affect metabolism and hunger.

At NY Health & Wellness, we’ve created a proven, science-based program that works with your hormones to control your hunger, appetite and cravings. Our new Balance 3H+ program resets the hormones that are making you feel sick, bloated, and unusually hungry! We specialize in hormonal weight loss programs and metabolic hormone balancing wellness plans that are designed to balance your hormones both naturally and effectively. All of our weight loss programs are predicated on a proven, integrative medical approach that has helped thousands of women nationwide achieve significant weight loss, look younger, and restore their energy at the fastest and safest pace possible. Our programs prove that “It’s not your fault, It’s your hormones!“

Balance 3H+ — What’s the “3H” and How Does It Affect Your Hunger and Weight?
Hormones are the body’s chemical messengers, and they travel through the bloodstream, delivering messages to tissues and organs throughout the body. Leptin, ghrelin and cortisol are the three most common hormones involved in the regulation of weight and weight-related senses like hunger and satiety. They need to be balanced in order for effective weight loss to take place.

Leptin
Leptin, which produced in fat cells, plays a significant role in the regulation of body weight. Through the effect that it has on the brain, leptin controls the feelings of hunger and satiety. Because it is secreted by adipose (fat) tissue, people who are overweight or obese tend to have higher levels of leptin, causing a vicious cycle that makes weight loss all but impossible.

Gherlin
Gherlin, also known as the “hunger hormone,” is produced by specialized cells that live in the lining of the stomach and the pancreas. When levels of ghrelin are high, the hormone works in conjunction with the brain to stimulate hunger, slow metabolism, and decrease the body’s ability to burn fat.

Cortisol
Cortisol is known as the “stress hormone.” It is produced in the adrenal glands in response to stress. When cortisol levels are high, the body will believe that it needs to store extra fat, making it impossible to lose weight. In this scenario, fat tends to accumulate in the abdominal region, which contains large quantities of cortisol receptors.

Learn about the revolutionary weight loss program that has helped thousands of women across the nation look and feel their very best. Call NY Health & Wellness at 914-703-4811 now to schedule a complimentary one hour medical weight loss consultation.

Mindfulness to achieve peak performance

If I could mange distractions during my sports performance, I’d be able to achieve my peak potential! Distraction and losing focus are very common experiences that athletes find challenging to manage. For example: A tennis player lost the last four games and, during the changeover, he starts having uncontrollable negative thoughts. Elizabeth is bound to shoot her best round of golf and, as she is about to tee off, she pays too much attention to the out of bounce on the right. Tom missed his first free throw and now must make the second one to tie the basketball game with one second left.

Regardless of how much we practiced, athletes are bound to feel the emotion of the game, especially when a significant achievement is on the line. Even top athletes feel the nervousness of the moment. A professional golf player will feel his knees shaking when playing in the Ryder Cup because he is representing his own country. Serena Williams succumbed to the pressure of wanting to win the Grand Slam when facing a fairly unknown rival. The wanting to win as well as the fear of losing is felt in our bones, muscles and skin. As much as we would like to control the external factors that are part of competition, it is the internal distractions that lead our minds into wandering.

When the mind is distracted, it follows scattered thoughts, negative scenarios or blank stares. The body responds by tensing up, sweating or shaking. Commonly executed shots, throws or pitches become so much more difficult to do well. Regardless of our competitive level, we are bound to experience pressure situations. In fact, it is the effects of our emotions that we feel while playing the sport that we love that makes its mastery so much more challenging, fun, and frustrating.

It is common that we find ourselves giving “orders” to our thinking brain so it avoids troubles. “Don’t double-fault now” or “don’t hit it into the water.” Unfortunately, the brain interprets such instructions by becoming even more aware of double-faulting and water. Contrary to our well intended message, the brain is channeling even more attention to either situation as they are both perceived as threats. On the other hand, if we said, “serve well,” or “hit it over the water,” the thinking brain is unable to consistently control all the multiple body parts necessary to always meet such an expectation.

So, how do we learn to manage distractions? Learning to master distractions rests on focusing in the present moment without judgment. Being mindful helps us to see the behaviors that create our discomfort rather than impulsively react out control. Rather than being overwhelmed by an unpleasant result or clinging on the highs that come from achieving a successful outcome, being mindful helps us to be less concerned with the final outcome and more present with the efforts that we put into achieving our goals. The experience of mindful acceptance helps us to enjoy the present moment where the critical mind is a brief episode rather than a permanent feature.

Novak Djokovic wrote, “Now, when I blow a serve or shank a backhand, I still get those flashes of self-doubt, but I know how to handle them. Mindfulness helps me process pain and emotions. It lets me focus on what’s really important. It helps me turn down the volume in my brain. Imagine how handy that is for me in the middle of a grand slam championship match.”

Mindfulness promotes resiliency. When consistently practiced for about 15 minutes on a daily basis, the right side of the brain, which is more connected with emotions, becomes less active. Meditation helps to contain emotional peaks and valleys. Whereas non-experienced meditators would emotionally quickly respond to adverse situation by losing focus and getting distracted, meditators would have a greater ability to emotionally contain such distractions. In a recent study conducted by Yale University, it was found that meditation lessens mind wandering and enhances emotional regulation.

Meditation can be practiced in many different ways. One of the most common techniques is that of paying attention to the breath. Start by choosing to either keep your eyes opened or closed. Sit in a comfortable seat where your back is straight and both feet on the ground or legs crossed. Then, pay attention to each breath by either noticing the colder air coming in and the slightly warmer air being exhaled through your nose or push your belly out with each inhale and down with each exhale. Continue to be aware of the breath, one cycle at the time. You may notice that thoughts are likely to enter the mind. Just notice and give them permission to move on. If you became distracted by the many thoughts that came in, you have just become mindful of that new experience. Rather than taking your mind to those thoughts, bring your awareness back to the breath. After 15 minutes, slowly bring back your awareness to where you are sitting, the space around you and your body.

As we gain awareness of our mind and breath, the external distractions will occupy less attention from us. We cannot avoid being distracted from everything around us, but we can gain the ability to bring our attention back to our present moment experience. Present focus is what really matters to any athletes.

Alex Diaz, PhD
Sports Mental Edge

Preventing Overuse Injuries in Youth Sports

Overuse injuries are on the rise in youth sports but many can be prevented fairly easily with the right information. These are injuries that occur over a period of time due to repetitive stress loads on tissues without adequate rest and recovery. Examples are tendinosis/tendonitis, stress fractures and strains. They are not the result of a specific major traumatic event, such as a fall, collision, etc.

There are many factors that can lead to overuse injuries. Some of these include the increased competitive nature of youth sports and lack of variety of sports/activities, overtraining, faulty biomechanics, inadequate conditioning and flexibility, inadequate warm up/cool down routines, poor nutrition/hydration, lack of sleep and genetics. The good news is that all of these, with the exception of genetics, can be changed. Let’s now take a look at some of these.

Genetics
Let’s start with the genetic factor, the one that cannot be changed. People are born with structures that will make it easier or more difficult to perform certain activities. There is such a thing as a structural advantage. The way bones are structured allowing for joint range of motion or the structure of a muscle and location of its tendon attachment determining contraction capabilities are some examples of this.

Also, levels of integrity of the connective tissues can be a genetic factor as well. Some people’s tissues can handle higher amounts of stress loads than others before breaking down. This can often be the determining factor in athletes who do end up making it to the elite levels.

Training patterns and Variety
A serious problem seems to be the increased competitive nature of youth sports. There seems to be more focus on young athletes making it to the pros instead of simply enjoying the sport. This can lead to overtraining. Well-roundedness and cross-training is very important to maintain balance in the musculoskeletal and nervous systems. Performance level will often increase when the young athlete participates in a variety of activities instead of just one year round.

Training Patterns And Mechanics
Mechanical imbalances are a major issue in the world of overuse injuries. These include limited ranges of motion due to muscle/connective tissue tension or adhesions, poor technique in the performance of the activity and poor posture in daily life. Things like prolonged sitting and looking down at a smart phone or tablet repeatedly can create a foundation of mechanical dysfunction that can increase the risk of injury.

Another major issue is that too often young athletes do not warm up or cool down properly, which significantly increases the risk of injury. Warm ups should include dynamic stretching, or stretching that involves active movement in order to stimulate circulation and neuromuscular activity and lubricate connective tissues. Cool downs should include static stretching, or holding the particular stretch position without movement. Static stretches should be held at a comfortable level of stretch tension for 30 seconds. These warm up/cool down periods are just as important than the workout itself.

Preseason conditioning is also important and can help to prevent injury. This should always include basic core conditioning, neurosensory (balance) training and flexibility, which are important in all sports, and sport-specific movement conditioning.

Although preseason physicals are usually a requirement for organized youth sports, screenings that are more movement/function-specific in addition to the physical can also help to spot subtle imbalances before they lead to something worse.

Nutrition
Adequate nutrition is an essential component of performance level, injury risk and overall health in general. It is unfortunately very common to see young athletes with terrible diets – either eating unhealthy foods, or just not eating enough. Nutrition provides the building blocks and fuel the body needs to perform. It is only logical that what we put into our bodies will directly affect the output. Consume healthy protein and fat sources, along with enough fruits, vegetables and other complex carbohydrates. Avoid junk foods, soda, juices that are not 100% fresh squeezed, and sports drinks. Consulting with a sports nutritionist can be very helpful to establish an individually appropriate routine.

Rest and Recovery
Sleep is one of the most underrated aspects of health. A recent study in the Journal of Pediatric Orthopedics shows that adolescent athletes who get under eight hours of sleep per night have a significantly higher risk of becoming injured than those who get over eight hours. This can be due the fact that growth hormone, which is largely responsible for tissue repair, is released while we sleep. If we are not getting enough time for this repair process to take place, tissues will not fully recover from the stress of exercise and will therefore be more vulnerable to break down.

Another study showed that lack of sleep can negatively affect performance, decision making and proprioception, which is something like balancing an internal coordinate system. This is a sensation responsible for positional sense of the body’s parts during movement and rest – basically where we are in space. For example if my eyes are closed and I move my arm up over my head, I know where my arm is, not because I can see it, but because I can feel it. This has a lot to do with muscles firing at the right time in order to coordinate movement. So if this system is not functioning to its fullest potential, one’s balance will be less than optimal increasing the risk of falls and other injuries.

Playing Through Pain
Playing through pain for a youth is not a good idea. Pain is an alarm system warning us that something is not right internally and there is danger of further damage. Playing through pain will often be counterproductive in the long run, because the condition can worsen leading to an injury and possibly cause other problems due to imbalances and compensatory patterns.

In athletics, as in many areas of life, persistence through hardship in order to achieve a goal is a tremendous and commendable attribute. But it is important to listen to the body when it is trying to tell us something. It is great to be tough, but we must also be smart. If there is pain during the activity, seek the advice of a sports medicine professional.

We should also note that there may be mental/emotional factors at hand, too. This can significantly affect the way we interpret stimulus and perceive pain. The issue of a young athlete under mental stress who may be afraid, or simply not want to play is certainly something to take into account. Open communication between parents, kids and coaches can help in determining what is really going on. Consulting a sports psychologist can also be very helpful in these matters.

Conclusion
The purpose of this article is simply to raise awareness on a prevalent issue. There are countless variables in this topic, so getting into specifics would be too extensive for this newsletter. Being mindful of the above factors is a great starting point in preventing injury.
When in doubt, consult a professional. Prevention is always the best medicine.

Are You Really What You Eat?

There is an old popular adage that states, “You are what you eat,” implying that in order to be fit and healthy you need to eat good food. While this notion is certainly true, it is complicated by our modern food supply. It is no longer enough to eat a balanced diet full of whole grains, lean meats, and fresh fruits and vegetables and expect to have adequate nutrition. Data collected by the US government shows that there has been a decline in the nutritional content of our fruits and vegetables. The USDA has proven that store-bought fruits and vegetables have far less vitamins, minerals, and nutrients than they did 40-50 years ago. One study shows we would have to eat 8 oranges today to get the same amount of vitamin A our grandparents would have gotten from one orange!
The past five decades have been known as the “Green Revolution” which is demonstrated by the increased production and yield of the fastest growing and greatest producing plants. The decline of the nutrients in our crops is due to soil depletion during this mass agricultural phenomenon. The soil that most of our crops is grown on is so deficient in mineral content that our produce contains only about 10% of the vitamins and minerals they should have! Our soil quality has decreased because of the modern intensive agricultural methods that are used to improve size, growth and pest resistance.
Most plants require nitrogen, phosphorus and water in order to grow. However, if they are grown in soil without other nutrients present, the plants will be devoid of any nutrition, even though they will look good to the naked eye. The absence of nutrients in the soil creates plants that are less able to defend themselves against natural predators, and thus they require pesticides in order to protect themselves from damage. These chemicals sprayed on our fruits and vegetables are poisonous and have not been properly tested to determine their effects on humans.
Even though fruits and vegetables are not as healthy as they used to be, we should not avoid eating them. They still have beneficial nutrients, fiber, and phytochemicals, and they are much healthier than processed foods and other snacks. Buying organic and local fruits and vegetables helps preserve the nutrient content in our produce and helps us avoid damaging chemicals and pesticides.
So, continue to eat the rainbow of foods in front of you, but also realize that it might not be enough. You may need to replace the missing vitamins and minerals in your diet with nutritional supplements. A good multivitamin might go a long way in helping to ensure optimal health and nutrition and to make sure that you are, in fact, what you eat.

How to Effectively Use a Self-Talk Strategy: New Research Findings Will Surprise You

Self-talk has been used by athletes for years for the purpose of controlling emotions and bringing focus back to task. Short phrases expressed in a positive present tense help to alleviate normal performance pressures. “I can do it,” or “I am in the zone” are typical self-talk statements that are commonly expressed to bring attention to the task at hand. They are short, straight to the point, and easy to remember.

But, did you know that expressing a self-talk statement in the second or third person may actually improve its effectiveness? In a recent observation, psychologist Ethan Kross noticed that a self-talk expressed in a second or third person (you or he/she), instead of in first person (I), creates further cognitive clarity and an emotional distance from the person expressing such a statement. In other words, expressing a self-talk that does NOT start with “I”, but rather a second or third person, helps to not only regain focus for the task at hand, but also to push away the emotional response linked to expressing such a self-talk.

Dr. Kross noticed that when LeBron James was explaining his frustration, he referred to it as, “I wanted to do what was best for LeBron James, and to do what makes LeBron James happy.” Just listening to how he talked, it seemed as if he was talking to another person also named LeBron James. The way LeBron James expressed his frustration allowed for the creation of an emotional distance between his own upsetting words and its understandable emotional reaction. He was able to remain calm and collected while talking about an upsetting experience. A self-talk used in a second or third person lessens the emotional connection of the words being expressed.

In an article written by Weintraub, she explains that the benefits of this style of self-talk are engrained in a communication pattern used during our early developmental stages. When toddlers play with their imaginary friends, it is quite common that they engage in a dual verbal interaction. Toddlers typically provide words to their imaginary friends for the sake of continuing the playing engagement. For example, little John is playing with his trains and says something like: “Now, we put that train there and then we can push it to the end, but do not start yet, ok?”

Unbeknown to the toddler, at a very early age, he/she is starting to develop a coping skill that sooths the playing experience and saves him/herself from the stress of playing by him/herself. The early brain, which is in its prime stage to develop long-term memory, stores these engaging and soothing experiences, which may be retrieved in adulthood. Beck, a child psychologist, believes that early self-talks elicit neural connections in the emotional area of our brains, which lead to lifelong learning while enhancing soothing responses.

Even as adults, we can still express upsetting emotions in second or third person and not feel the concurrent distress. For example, a tennis player feels quite nervous as he is about to play an opponent who is ranked much higher than he is. His palms are sweating, he is short of breath, and his heart is pounding quite fast. At this moment, he would greatly benefit from using this style of self-talk to soothe his nerves. He may say something like: “John, you have trained very hard and put a lot of effort to make it this far; go out there and give it your best try. It does not matter if you win or lose. Just enjoy this great playing opportunity.”

This style of self-talk invites a combination of calmness and concentration. The self-talk is still zeroed in on bringing the best out of his game and is presented in an optimistic and empowering chat. However, its content projects an emotional distance, which allows for clarity in his thinking and more calmness of his emotions.

Whether you are on a golf course, a tennis court, a soccer field, a running track or just about to give an oral presentation before many unknown people, remember that it is normal to feel nervous. Secondly, use a self-talk style that is expressed as if you were talking to yourself. And, thirdly, envision yourself having fun and successfully accomplishing your task.

Enjoy your summer and every opportunity you get to play your favorite sport!!

Alex Diaz, PhD
Sports Mental Edge®
www.sportsmentaledge.com

How to Find a Good Doctor and Surgeon

How to Find a Good Doctor and Surgeon

Rick Weinstein, MD, MBA

Director of Orthopedic Surgery

It is extremely important to make sure the doctor who takes care of you is a good doctor. You are entrusting him/her to either maintain your health or to get you back to good health. This is even more important when it comes to finding a good surgeon. You are entrusting this person to diagnose you correctly and then cut you open to fix something internally.

When choosing a doctor, I think the most important criteria is to make sure you have a person with whom you can have good relationship. It should be someone you trust and who you feel comfortable asking questions to. There are too many doctors who don’t make eye contact with their patients or can’t have a conversation with them. If this describes your doctor, go somewhere else! If your doctor spends more time looking at the computer than at you, go find someone else! Do you need to make an urgent appointment, and there is no availability for a few days? Then go somewhere else and find a doctor who values your time as much as his/her own.

How about a surgeon? How do you find a good one? First, ask your family, friends and co-workers who they have used and if they were happy. The best source for a surgeon is the doctors or nurses who work directly with the surgeon; if you can get their input, you are more likely to find a good surgeon. Does this surgeon work on amateur and professional athletes? If your medical doctor sends you to a surgeon, it may be just because he is required to recommend this surgeon as being part of the same practice. Ask your doctor if he has used this surgeon or would trust this surgeon to operate on his own family.

One of the best determinants of a good result for surgery is the number of procedures that surgeon performs. If he only does that procedure a few times per year, you are better off finding a doctor who practices more. Surgeons who do more of the procedure have fewer complications. Also, doctors who have to spend a lot of time performing a surgery because they are less experienced will require you to have more anesthesia, which leads to significantly more problems and complications.

The bottom line to finding a good doctor or good surgeon is to get references from reliable sources (friends, family, other doctors), to make sure you have a good relationship with the doctor, and to have faith in his/her abilities. You need a surgeon who is good at what he/she does, so make sure that surgeon has a lot of experience and performs a lot of that specific surgery.