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Skiing Knees

Dr. Stone practicing what he preaches. Courtesy the Stone Clinic.
Dr. Stone practicing what he preaches. Courtesy the Stone Clinic.

Nothing loads the front of the knees and the patellar tendons like skiing. When else is your body in a flexed knee position for multiple hours per day, absorbing the forces of moguls, bumps, and landings, combined with twisting, turning, flexing, and extending hundreds of times per hour? If you haven’t trained hard in the off-season, pain awaits.

Good pain is the soreness you feel early in the season. It’s mainly at the patellar tendon and hamstrings, which absorb the load and contract to hold the ski edge on the snow. This is the pain of deconditioning, and it improves with time on the snow. Good pain is the muscular soreness in the quads and calves as the forward-leaning ski boot position loads the muscles with each turn. Good pain responds to a little ice, stretching, warm baths before skiing, and massage afterwards.

Bad pain varies by injury and location. Front of the knee pain—which is often accompanied by grinding and clicking of the kneecap—may indicate damage to the articular cartilage on the undersurface of the patella. If it only hurts when skiing, there are a number of therapies that often work well. These include: 1) A patella sleeve that supports the kneecap, keeps the muscles warm and provides proprioceptive feedback; 2) Patellar stabilizing exercises; 3) Injections of lubricating fluid, which we now combine with growth factors that induce the joint lining to produce more lubrication (we have many patients with arthritic knees who come in for pre-ski season lube jobs); 4) A surgical repair of the damaged cartilage, which can be either a smoothing down of the frayed tissue or a paste grafting to regrow the missing cartilage; and 5) A replacement of the surfaces with a metal and plastic implant called a patellofemoral partial knee replacement.

Bad pain on the inside of the knee—often accompanied by popping or catching, pain with squats, or pain when pushing off on the inside edge of the ski—can have a number of causes. These range from simple overloading (due to the shape of the legs) to the tearing of the meniscus shock absorber, or an injury to the articular cartilage, to frank arthritis on the femoral or tibial surfaces. 

If the pain is getting in the way of your enjoyment of activities, a careful exam, X-ray, and MRI will help define the problem. Fortunately, in the 21st century, there is no reason to live and play with pain. Mild symptoms with little damage can be resolved with lubricating growth factor injections and rehab exercises. The meniscus is repairable and replaceable with donor tissue. Damaged articular cartilage can be repaired with articular cartilage paste grafts, while bone-on-bone arthritis can be relieved with partial knee replacement, an outpatient procedure that can have you back on your skis in three months.

Bad pain on the outside of the knee is similar to the inside, with the same therapies available.

Pain all around the knee—with X-rays that show bone-on-bone arthritis in multiple areas—may be unresponsive to rehabilitation and injections. This issue can be addressed by the reimagined and precise art of knee resurfacing, which is now done with robotic control and the absence of cement. The best implants allow the body to grow into the undersurface of the components, nearly eliminating any concern about loosening due to activities. With these new techniques, the more you ski the better you will do with your knees, and in life.

If you are in pain, solve the problem promptly. Playing forever means enjoying each and every day. We used to issue prescriptions that said, “Must ski powder.”  Now they just say, “Must ski.” But powder is always our preferred way to slide.

Hear the remarkable story from professional ski instructor Angela who saved her skiing career with a double partial knee replacement in one knee. 

New Laser Skin Resurfacing Technology Available in Truckee

Dr. Adam Wallach (Photo courtesy of Skin Cancer and Dermatology Institute)
Dr. Adam Wallach (Photo courtesy of Skin Cancer and Dermatology Institute)

Dr. Adam Wallach from the Skin Cancer & Dermatology Institute weighs in on laser technology and the new Quanta Evo Light™ laser coming to Truckee.

Q: Tell us a little about how the Quanta Evo Light laser works. 

A: This laser, which possesses impressive current technology, performs many functions that previously could only be achieved by multiple individual lasers. We are incredibly lucky to have this device right here in our small town.

Q: Besides hair reduction, which skin conditions/challenges does it treat?

A: The Quanta Evo Light can be used to treat red blood vessels and sunspots on the face, chest, and arms. It can also be used to perform the Elluminate treatment, a painless and highly effective way to rejuvenate the entire face. It eliminates blood vessels and sunspots while stimulating new collagen all in one laser session. This unique treatment is performed using four sequential laser passes of different wavelengths that each treat a specific target of the skin.

Q: How is this laser different to others?

A: As previously mentioned, one laser can accomplish the same results of multiple lasers. It is a state-of-the-art laser that provides almost every functionality one might need as a dermatologist!

Q: What does this laser procedure entail?

A: Firstly, we start with a consultation to discover what you, the patient, wishes to remove or improve. Pretreatment photos and consent are done prior to any procedure and on occasion topical anesthetic is applied to the skin 15-30 minutes before commencing treatment. Patients are most often placed in a reclined position and eye protection is worn by both patient and physician. The laser procedure can take anywhere from 15-45 minutes depending on the treated areas/skin conditions. Once treatment is complete there is often cooling with ice and then an aftercare product is placed on the skin. Finally, the patient is given post procedure instructions and a plan for follow-up is made.

Q: Will it hurt and is it safe?

A: Generally, these procedures do not hurt, although there can be a slight tingling sensation.

Q: How many treatments, on average, are needed to see results? 

A: Some laser procedures, like the treatment of facial blood vessels, produce a noticeable change the moment you leave the office, with only a few days of redness. Sometimes, for example, if one has a very intense problem a second procedure might be needed one to two months later. Other rejuvenating procedures like the Elluminate treatment require two to three treatments spaced four to eight weeks apart to really undo significant aging produced by the sun. Laser hair removal often takes four to eight treatments to effect a lasting change.

About Our Dermatology Providers

In private practice since 1997, Dr. Wallach treats patients at Skin Cancer & Dermatology Institute’s Truckee location. He diagnoses a full range of dermatologic problems for both adults and children, and specializes in medical and cosmetic dermatology, including the use of various lasers over the last 25 years. He is a strong proponent of patient education in his practice and is the contributing author to the chapter on skin in the upcoming book, “The 21st Century Man.” Dr. Wallach and his family live in the North Tahoe area. Get to know Dr. Wallach and book an appointment online here.

Bringing you patient-centered, world-class dermatological care with nine locations in the Reno-Tahoe area. Skin Cancer & Dermatology Institute specializes in medical dermatology, Mohs skin cancer surgery, and cosmetic dermatology.

Drs. Hibler and Wallach Talk Skin Cancer – An Insightful Q&A with Medical Dermatology Providers

Get to Know Our Dermatology Experts

Dr. Hibler calls North Lake Tahoe home and sees patients at the practice’s Incline Village location. Specializing in medical, pediatric, surgical, and cosmetic dermatology, his approach as an osteopathic physician focuses on treating the whole person. 

In private practice since 1997, Dr. Wallach treats patients at the practice’s Truckee location. He diagnoses a full range of dermatologic problems for both adults and children, specializes in medical and cosmetic dermatology, and is well known for treating many types of skin cancer. Dr. Wallach and his family live in the North Tahoe area.

J. Hibler. D.O.
J. Hibler. D.O.

J. Hibler, D.O.

Q: What types of skin cancer are there?

A: There are several different types of skin cancer, but the two main categories are: 1) malignant melanoma and 2) non-melanoma. The second category is divided into basal cell carcinoma and squamous cell carcinoma. Basal and squamous cell carcinoma are much more common than melanoma, but typically not as dangerous as melanoma. Melanoma can grow on any area of the body, even where sunlight does not reach, which is why we are so keen to encourage our patients to not only perform monthly self-exams, but also get full skin exams at least once per year with a dermatology provider. For those with a family history of skin cancer or who have been treated for skin cancer before, full skin exams should happen more frequently.

Q: Is skin cancer hereditary? 

A: Some very rare types of skin cancer are hereditary, and there is a genetic component to some melanoma types of skin cancers. Talk to your dermatologist about your family’s history of skin cancer as it is an important factor.

Q: Are there common places that skin cancer is found in men or in women?

A: Most skin cancers are found on sun-exposed areas. In men it is often the chest or back areas and in women the legs are most frequently affected. But it is important to know that melanoma, the most dangerous form of skin cancer, can be found anywhere, including unusual and non-sun exposed areas which makes thorough full skin exams so critical.

Q: What should we know about practicing sun safety during the winter months?

A: Living in the Sierras and surrounding desert areas such as Reno, Carson, and the central California valley, brings a unique dimension to our daily sunscreen usage. Both altitude and the amount of sun days in these areas make sunscreen an integral part of our daily routines in every season, including winter. Sun exposure and the damage it causes is cumulative, so getting into the practice of wearing sunscreen year-round is highly recommended.

Q: Is light therapy safe to use? Can it increase the risk of skin cancer? 

A: The light therapy prescribed by dermatologists to treat certain conditions is a specific wavelength of light that is beneficial to the skin and it acts as an overall anti-inflammatory. Natural sunlight contains the whole spectrum of light which includes the good and bad wavelengths, so only small 20–30-minute doses of natural sunlight without protection is okay.

Adam Wallach, M.D.
Adam Wallach, M.D.

Adam Wallach, M.D.

Q: What should I be looking for to help detect skin cancer? 

A: The most important starting point is knowing the existing spots on your skin. If you are over the age of 40, the moles you have should be unchanging, although you may acquire or have changeable spots like sunspots or liver spots or keratoses as you age. The trick for all age groups is to identify spots that look different than your usual crowd of spots. Put another way, look for the ugly duckling or lone wolf on your body. Not infrequently, cancers may bleed, and on occasion a mole that is becoming malignant will itch. Here is where I emphasize the importance of getting to know your spots through regular self-exams. Check your entire body at least once per month and have a family member help check those hard-to-reach spots or use a mirror.

Q: What are the most unusual places that you have detected skin cancer on a patient? 

A: Skin cancer can occur in almost any area of the body, including those areas where the sun does not reach. I have detected skin cancer on the eyelid, between the toes, on genitalia, within the nose, and under the fingernail.

Q: What is Mohs micrographic surgery? 

A: First developed in the 1930s by Dr. Frederic E. Mohs, this type of dermatologic procedure is considered the gold standard for skin cancer surgery. It differs from standard dermatologic surgery in that the tissue is examined histologically at the time of removal.  If there is still cancer remaining, successive stages of skin are removed until the histology is clear. This technique is used principally for large or recurrent cancers, cancers located in difficult locations like the nose, eyelids, and ears, and for cancers with aggressive pathology. It is an out-patient surgery that can be relatively quick, or take all day, based on how complicated and how large the cancer is. Your dermatologist will prepare you with their expert tips on how to prepare for the day of surgery.

Q:  If I have scars from skin cancer treatment, are there ways to diminish their appearance? 

A: The most common scars that result from skin cancer removal are the white lines one sees where the excision occurred. Fractionated carbon dioxide lasers do a great job at blurring these white scars. The other common scarring that one sees around excision sites is the secondary development of blood vessels or telangiectasias. These vessels most often are triggered because of the healing process, but they often give an exaggerated redness to the surgical area. Pulse dye and KTP lasers, which we use at Skin Cancer & Dermatology Institute, do a great job at removing these post-surgical excessive vessels.

Q: Tell us your three favorite sunscreens and why? 

A: My favorite sunscreens are from EltaMD®. My daily use sunscreen is EltaMD UV Clear SPF 46. It is super lightweight and a favorite among my patients with normal to oily skin. This is also the only tinted sunscreen I have found that almost all men like and which blends upon application without any unusual trace of color. For outdoor sports, I use EltaMD UV Sport SPF 50 which is an amazing water-resistant sunscreen that does not feel tacky like most sport-type sunscreens. Remember to reapply sunscreen liberally and frequently. Finally, I love EltaMD UV Lip Balm SPF 36 for lip protection. Do not forget that every part of our skin needs protection, including the lips.

Learn more about skin cancer, schedule a full skin exam, and get to know Skin Cancer & Dermatology Institute’s medical providers online.

About Skin Cancer & Dermatology Institute

Your Reno-Tahoe area experts combine market-leading skin and patient care with the most advanced technology and lasers. With nine convenient locations, Skin Cancer & Dermatology Institute has been treating caring for our community for more than 20 years.

Skin Cancer & Dermatology Institute

Six common psoriasis questions, answered by dermatologists

Bringing you best-in-class patient care with the most advanced technology and lasers. With nine locations in the Reno-Tahoe area Skin Cancer & Dermatology Institute specializes in Medical Dermatology, Mohs Skin Cancer Surgery, and Cosmetic Dermatology.

Make your appointment today at SkinCancerDerm.com.

Psoriasis affects more than eight million people in the United States. Often painful and occasionally embarrassing, what is it, and how can it be treated? The Dermatologists at Skin Cancer & Dermatology Institute answer these and other common questions. 

Q: What is psoriasis?

A: Psoriasis is an auto-immune disorder that, according to the American Academy of Dermatology, causes the body to accelerate the production of skin cells in days rather than weeks. As cells begin to pile up on the skin’s surface, scaly patches are created. Patches can grow anywhere; however, the most commons areas are the scalp, elbows, knees, and lower back. Symptoms can start at any age, more often beginning between the ages of 15 and 25. Men, women, and children of all skin tones can get psoriasis.

Q: What causes psoriasis?

A: People who have certain genes are more likely to get psoriasis. If your parents, grandparents, or siblings have psoriasis, it increases the likelihood of getting it. 

Your immune system also plays a significant role. White blood cells (T-cells) are cells that help our body combat bacteria and viruses. With psoriasis, something goes awry in the immune system, causing the T-cells to attach to the body’s skin cells leading to the accelerated production of cells and the patchy areas. Once this process begins, it usually turns into a life-long concern. There is one exception for some children who get guttate psoriasis, a one-time condition that does not return.  

Q: What are the types of psoriasis and their symptoms?


Plaque psoriasis: is the most common form, affecting roughly 80-90% of those who develop psoriasis. Dry, scaly patches form anywhere on the scalp, elbows, knees, or lower back. Plaques vary in size, with small plaques frequently joining to create large plaques.

Guttate psoriasis: tiny bumps appear on the skin out of nowhere, covering most of the torso, legs, and arms and at times also developing on the face, scalp, and ears. The bumps are small and scaly, and the color varies from salmon-colored to pink. This type of psoriasis tends to clear up within a few months, or even weeks, and sometimes does not return. 

Inverse psoriasis: develops in areas where skin touches skin, such as armpits, and creates smooth, red patches of skin that look raw. Fungal infections can trigger this type of psoriasis. 

Pustular psoriasis: This rare form of psoriasis causes pus-filled bumps that appear on the feet and hands, sometimes mimicking an infection, although the skin is not infected. Extremely sore or painful skin with brown dots and sometimes scales as the pus-filled bumps dry. Since this type attacks mostly hands or feet, it makes activities like walking painful.

Generalized pustular psoriasis: causes pus-filled bumps, similar to pustular psoriasis, with the main difference being the bumps develop on most of the skin. According to the American Academy of Dermatology, when a flare-up occurs, it causes a sequence of events: skin on most of the body suddenly turns dry, red, and tender. Within hours pus-filled bumps cover most of the skin. Typically, within a day, the bumps pop, and pools of pus leak. Within 24-48 hours, the pus dries, leaving dry, peeling skin with a smooth, glazed surface. The cycle tends to repeat itself a few days or weeks later. Fever, headaches, muscle weakness may develop in tandem. 

Erythrodermic psoriasis: causes the skin on most of the body to look burnt. Other symptoms include chills, fever, muscle weakness, rapid pulse, and severe itch. Immediate medical care is required. This is the least common type of psoriasis. 

Nail psoriasis: causes tiny dents in your nails with white, yellow, or brown discoloration under one or more nails. Some people experience crumbling and rough nails. 

Psoriatic arthritis: this occurs when psoriasis affects the joints. If you suffer from any form of psoriasis, it is essential to pay attention to any irregularities in your joints. Some signs include swollen and tender joints, especially in a finger or toe, heel pain, swelling on the back of your leg, and stiffness in the morning that fades during the day. Without treatment, psoriatic arthritis can hinder movement.

Q: What triggers a psoriasis flare-up?

A: Everyday things can be triggers and vary from person to person. Some of the most common triggers are stress, skin injury (including a bad sunburn), infection (e.g., strep throat), some medication, weather (especially cold, dry weather), tobacco, and alcohol. 

Q: Is psoriasis contagious?

A: Rest easy. Psoriasis is not like chickenpox; it is not contagious. 

Q: Can psoriasis be cured?

A: The disease is often a sub-chronic disorder which ebbs and flows but does not resolve completely.

“While psoriasis is not curable, it is treatable with topical corticosteroid creams, light therapy, laser treatment or with injectable immunomodulatory drugs like etanercept (Enbrel®) or adalinumab (HUMERA®). Recent versions of similar medications like secukinumab (COSENTYX®) or risankisumab (SKYRIZI™) have become more targeted by diminishing inflammatory mediators specific to psoriasis without affecting other immune functions,” said Skin Cancer & Dermatology Institute’s newest Board-Certified Dermatologist, Adam Wallach. “There can be little to no blood work monitoring required, and while early immunomodulatory drugs consisted of weekly injections, some of the current ones call for only one self-administered shot just four times a year. Laser treatments can also deliver consistently predictable results. The clinically proven excimer laser, XTRAC®, can quickly clear psoriasis with many patients seeing significant improvement and long-lasting remissions.”

If you or a loved one are ready to take control of psoriasis, book a Medical Dermatology consultation online at SkinCancerDerm.com or call 775.324.0699. 

Is your vacation rental compliant with new local regulations?

Is your short-term rental in Truckee or Placer County permitted? If not, new regulations mean you could face steep fines and penalties.
How to get your rental compliant with new laws

ManageHome can help vacation home owners understand and get their short-term rentals compliant with the new regulations. Attempting to go through the new permitting process without professional expertise and guidance could increase your risk of missing an important step or rule. For more information about services and pricing, visit www.managehome.net.

Renting out your vacation home can be a lucrative endeavor, but new regulations could put do-it-yourselfers using AirBnB, VRBO or other similar services into risky compliance territory if just one single step is missed or misrepresented.

All short-term rentals (STRs) in Truckee are required to register with the town every year beginning in 2021. In Placer County, similar regulations have been in effect since January 2020. Obtaining these required short-term rental permits from the town or county is more complicated than simply paying a fee, but one local business wants to make the process as smooth as possible for local vacation homeowners. 

“The penalties and costs of noncompliance are high,” said Steve Klei, co-founder of ManageHome, a new Truckee-based business that provides step-by-step guidance through the short-term rental permitting process. “We started ManageHome because we realized that the new regulations were causing a tremendous amount of concern and uncertainty with those who are renting their home. We believe the services will be helpful to improving visibility and compliance on key issues like health and safety, fire prevention, as well as from a neighborhood relations standpoint.”

Steve Klei, co-founder of ManageHome.

Klei and his partner, ManageHome co-founder Meghan Stokes, have each been local residents for more than 30 years. They’ve now also become local experts on the new short-term rental regulations, specifically the self-certification form that all homeowners must fill out and sign as part of the permit application. 

Here are some of the top reasons they believe the average do-it-yourself vacation homeowner might need this kind of expert guidance through the process. 

Certification of compliance required 

Both Truckee and Placer County require that owners certify in writing prior to permit issuance that they are in compliance with the new rules. This includes things like having the right type and quantity of fire safety equipment, defensible space requirements, BBQ placement, building code compliance, parking and garbage storage to name a few. Klei and Stokes believe many homeowners could end up misrepresenting some of the points on the form if they don’t fully understand the requirements. Even worse, they think many homeowners may not even know the rules exist or are too overwhelmed to get permits at all. 

“People aren’t understanding how important it is that they take care of this,” Stokes said. “It’s a law — you can get fined and you can lose the right to rent your house at all.”

Non Compliant homes identified by specialized company

It might be tempting to avoid the paperwork and hassle due to the complexity, cost or amount of time it would take to get into compliance, but the risks of getting caught have increased. 

Both Truckee and Placer have contracted with a third party company to identify unpermitted STRs. Those without the permit will be subjected to potentially significant fines.

Permit requires a local contact person

Meghan Stokes, co-founder of ManageHome.

One of the most significant requirements in these short-term rental permits is an always-available local contact. This person has to be available by phone within a specific time frame, 24/7, and able to resolve complaints immediately. In Placer County as an example, the local contact must be able to be physically present at the rental within 30 to 60 minutes of a complaint. 

ManageHome is fulfilling this requirement as a service to its customers for less than $29 per month, which could save homeowners big money in the long run. 

“Fines are as high as $500 per day for each violation, and up to $1,000 per day for subsequent violations, but the even bigger risk is termination of the permit after a number of violations” Klei said. 

Health and safety 

The Town of Truckee and Placer County aren’t implementing these regulations for the money, Klei said. There’s an essential health and safety aspect to these regulations. The fees are basically covering the increased costs.

“If all of these things are done right, ManageHome can reduce homeowners’ liability,” he said. “If a homeowner self-certified, but they didn’t have the right smoke detectors yet thought they did, that’s a huge problem. You can’t skip or misrepresent a single detail on these permitting forms.”

Stokes added that the fire departments are in full support of these regulations for the safety of our local communities. Fire departments will be required to perform periodic compliance checks for both in-home safety and outdoor defensible space.

If you go to a hotel, there are certain expectations about the health and safety of that place. This is no different,” Klei said. 

Being a good neighbor

Klei said that one of the reasons these STR regulations are being pushed is that the guests in some of these vacation rental homes have been a nuisance for neighbors who, for example, find themselves dealing with loud partying, strewn garbage, cars parked all over or other issues. 

“Besides health and safety, these regulations speak to the desire for positive community relationships and neighbor relationships,” he said. “Hopefully the framework for these rules will go a long way towards those relationships.”

Protecting the local economy

South Lake Tahoe is moving toward an outright ban of short-term rentals, and many second-home owners around North Lake Tahoe are fearful that could happen here, Stokes said. “It affects their income and the whole economy,” she said. “Ideally, these regulations are in place and work in order to keep that (short-term rental income) as an option up here.”

With services such as ManageHome that help get homeowners fully compliant with the law, Klei and Stokes hope to help protect the long-term viability of short-term rentals and the overall positive impact to the economy throughout the region. 

“Everyone who has a short-term rental has to do this or we’ll all get penalized,” Klei said, “so we have to all pay attention to this.”