The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

October 21, 2008 #3,379 Editor-Barry Block, DPM, JD

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Barefoot Running Not for Everyone: DC Podiatrist

The jury’s still out on running barefoot. Whether your body can tolerate it or not may depend on your foot structure, but there is some doubt about how helpful barefoot running is for most people.

Dr. Stephen Pribut

Stephen Pribut, a private practice podiatrist in Washington, D.C., shows some of his patients how to strengthen their foot muscles by picking up a towel with their toes. However, he maintains that “you’re not going to un-pronate your foot by exercising any muscle in your foot.” Overpronation, or excessive rolling inward of the foot, happens because of bone structure, he says. In other words, some biomechanical problems will not be corrected by strengthening the feet.

Pribut, who is also on the board of advisors for Runner’s World magazine and a former president of the American Academy of Podiatric Sports Medicine, suggests that only runners with a certain arch shape should try barefoot running. “Some people’s feet are just built for needing guidance” from shoes, like people with low arches, he says.

Source: Rachel Mahan, Scienceline [10/20/08]

SBi Ilizarov Course in Siberia a Success

From September 26-October 5th 2008, Small Bone Innovations sponsored a group of 12 podiatrists who traveled to Kurgan, Russia to spend the week refining and learning about osteosynthesis at the Russian Ilizarov Scientific Centre in Siberia, Russia.

This is a group shot of the podiatrists, along with the translators and professors.

The surgeons who attended were David Gitlin, Jeff Karr, Robert Fryberg, Jonathon Key, Art Tallis, Bradley Koppel, Tim Holmes, Trevor Davy, Gerald Mauriello, Jr. ,Kenneth Seiter, Atta Asef, and Richard Weiner.

The Centre is an 800-bed orthopedic hospital in the Southern Siberian city of Kurgan. The Centre was founded by, and later named after the late Professor Gavriil A. Ilizarov (1921–1992) who developed the technique of transosseous synthesis with the use of his compression-distraction external fixator in 1951.

Healthcare IT: To Prompt 'Global Revolution' in Industry

The U.S. healthcare industry "is about to undergo a global revolution driven by a force it can no longer resist: information technology," the Wall Street Journal reports. According to the Journal, physicians and hospitals "have long been quick to adopt breakthrough technology in medical devices, procedures and treatments," but "far less attention has focused on innovations in networking and communications," in part because of "concerns about breaches in security and patient privacy and because healthcare until recently was a service always performed locally and in person." However, "that is about to change," the Journal reports.

"Outsourcing and off-shoring of medical and non-medical services will increase, providing more efficient healthcare at the most cost-effective rates; systems integrations will allow more medical records to be transferred swiftly and securely; efforts to monitor the safety of medicines will gain global access to data; and professionals and patients will find authoritative and up-to-date information on every specialty online," according to the Journal.

In the future, "there will be three often overlapping modes of delivering healthcare services: services performed in person by humans, services that can be performed by people at a remote location, and services performed by computers without direct human involvement," according to the Journal. Such "changes won't come quickly" and will face "plenty of obstacles" as institutions and networks reach across borders and encounter different laws as well as technical standards," but healthcare "organizations that don't join in the coming changes will incur higher costs and less integration," both of which "will make them less competitive in the global healthcare marketplace."

Source: A. Gupta, Wall Street Journal via American Health Line [10/20/08]

4 Words to Remember

Make this your management mantra" "Avoid confusion through inclusion." Lodge that phrase in the back of your mind. Why? Repeating this simple phrase will remind you to make sure that everyone understands your practice's objectives and that you will work to ensure that everyone understands the big picture, as well as individual tasks.

Adapted from: The Rule of Business, Fast Company's Editors and Writers

RE: Mid-Arch and Met Pain (Kel Sherkin, DPM)
From: Multiple Respondents

With the limited information available in Dr. Sherkin's post, here are my suggestions:
1) Temporarily take the orthotics back from your patient and apply a low Dye-type tape strapping and incorporate a felt 1/8" thick arch and dancer's pad with a cut-out under the 1st metatarsal head, but keep the pad at a full 1/8 thickness under 2,3,4,ad 5th met heads to support the forefoot valgus. Try to have the patient stay taped for up to 3 days. See how her symptoms respond to this.

2) You might then want to take new foot impressions and check these impressions to see if they capture the feet as you have measured and then phone your lab for a consultation with someone who can help you with the Rx.

Keith L. Gurnick, DPM, Los Angeles, CA, keithgrnk@aol.com

When sharing a biomechanical case on-line, it is helpful to include lesion pattern, postural complaints, pedal complaints, shoe wear, and x-ray changes. Off and on weight-bearing lateral photos are often helpful as well. That said, and from this distance, in Neoteric language, the patient has a rigid rearfoot (with its expected equinus influence) foot type but Dr. Sherkin has not stated whether or not the first ray elevates or remains stable when weight-bearing. Her left foot FHL does suggest that that side does have flexible forefoot foot type mechanics and also suggests that the symptomatic left side is longer than the right (any unmentioned unilateral postural or lower back complaints?).

Callus sub 2nd or IP Hallux would confirm my diagnosis as sub 1st met callus would tend to a more rigid forefoot. Her diagnosis is rigid rearfoot, flexible forefoot functional foot type, short right. I would cast her rearfoot Root neutral and plantar-flex the first ray using forefoot vaulting technique. B/L. I would use a zero to two degree rearfoot varus post and a 2 mm .heel lift, left and a 4.mm. heel lift, right. I would post the forefoot with a three degree 2-5 ff varus post and a fairly aggressive 1st ray cut-out, B/L.

Dennis Shavelson, DPM, NYC, NY, drsha@foothelpers.com

Look at her existing footwear for size, wear patterns and style. Try changing her footwear. If she’s wearing a high heel shoe, lower the heel. If she’s wearing a flat shoe with no support, recommend a more supportive shoe. And always check shoe size. Most adults wear shoes that are too short.

Robert S. Schwartz, C. Ped., New York, N. Y., rss@eneslow.com

RE: Monofiliments Not An Accurate Test of Neuropathy (Peter J. Bregman, DPM)
From: Lee Rogers, DPM, James J DiResta, DPM,MPH,

Dr. Bregman's opinion is fundamentally flawed. The 5.07 monofilament is not advocated to diagnose neuropathy, but to diagnose loss of protective sensation (LOPS) from neuropathy. Also, it depends on the location and number of sites tested to produce the correct result. The monofilament test has been proven in many trials to predict ulceration in patients with diabetes. The PSSD machine is not an accepted method to diagnose neuropathy or loss of protective sensation. It is a proprietary instrument that costs 10's of thousands of dollars, versus pennies for a monofilament.

There is a steep operator learning curve for the PSSD and it does not correlate with the most objective neurological test, the EMG/NCV. Furthermore, the PSSD is popular to determine the need and effectiveness of surgical nerve decompression in diabetes. Both the American Academy of Neurology(1) and the American Diabetes Association(2) have recently published position statements refuting the surgery as an effective treatment for diabetic neuropathy. There has only been 1 prospective trial of nerve decompression surgery at Grade IV (low level) evidence. The monofilament is not dead, it is alive and well. The combination of a monofilament test with a vibratory perception threshold (VPT) from a biothesiometer is more sensitive at detecting LOPS.

1. Cornblath DR, Vinik A, Feldman E, Boulton AJM. Surgical decompression for diabetic sensorimotor polyneuropathy. Diabetes Care 2007;30:421-422
2. Chaudhry V, Stevens JC, Kincaid J, So YT. Practice advisory: Utility of surgical decompression for the treatment of diabetic neuropathy: report of the American Academy of Neurology. Neurology 2006;66:1805-1808

Lee Rogers, DPM, Des Moines, IL, lee.c.rogers@gmail.com

I felt compelled to respond to the recent comments of Dr. Peter Bregman on PSSD testing as a better screening tool for peripheral neuropathy. In his comments, he infers that this is the new "gold standard" in diagnosing peripheral neuropathy which is a dangerous assumption. While it is true that PSSD is a highly sensitive test and therefore more likely to "capture" more patients with neuropathy, it lacks specificity, thereby finding many false positives and potentially labeling sick people as "sicker" when they are truly not at any more risk. The added danger of the so-called "potential benefit" of finding patients for "early" surgical intervention with surgical decompression based on this testing is also disturbing.

For us, as our country's leading foot healthcare providers, to promote such an algorithm of care with PSSD, a costly test compared with the simple and inexpensive monofilament testing in the process of screening for peripheral neuropathy is not the new standard of care. There is truly minimal gain and potential harm with PSSD use as a screening tool which is just not supported by the present literature and cannot justify the cost to our healthcare system at this time. Use of PSSD testing is for pre-surgical assessment and even at that, questionable, as it promotes intervention in a manner that is still in dispute.

James J DiResta, DPM, MPH, Newburyport, MA, jsdiresta@comcast.net

RE: Kudos for Dr. Moore
From: Mike Rosenblatt, DPM

I would like to congratulate Dr. Moore on his superb article on "Maximizing Outcomes and Revenue through Integration of Protocols" (PM Magazine, Oct. 2008).

I cannot imagine a more effective way to use forms to educate patients, maximize income and powerfully improve patient care. There are REASONS why some podiatrists do vastly better than others. These issues are glossed over or ignored by critics of the profession, from inside and out.

Dr. Moore’s articles should be on the "must-read" list of every practicing DPM. Even more important, podiatrists should adopt and use Dr. Moore's concepts to immediately improve their practices. His concepts can lead a revolution in modern practice.

Mike Rosenblatt, DPM, San Jose, CA, rosey1@prodigy.net

SUBLET SPACE WANTED - NORTHERN NEW JERSEY

Busy multi-specialty podiatry group looking to hire a motivated individual to work part-time, including weekends as a podiatric hospitalist. Immediate opening available. NYS license a must. Applicant should be well-trained in all aspects of surgical and wound care and have completed a 24-36 month residency. If interested please send CV to docbunion@yahoo.com

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for full-time podiatrist in a multi practice location in the Chicagoland and Northwest Indiana area. Must have two years of surgical residency. Please e-mail resume to d-kitchens@footexperts.com

SURGICAL EQUIPMENT FOR SALE

One Storz-Ergo Surgical Kit - Oscillating and reciprocating plus K-Wire driver. In very good operating condition. $4,500.00 Complete set of surgical instruments for any type of foot surgery. Includes osteotomes, implant prep osteotomes, hemostats, rongeurs, Allis clamps, retracters, bone forceps, etc, in excellent condition. Approximately 80 instruments. $1,500.00. e-mail Marstubass@aol.com

SURGICAL PODIATRIST - CONNECTICUT

Connecticut Surgical Group, one of the largest multi-specialty surgical group practices in New England, is seeking a Board-Certified podiatrist to add to our four-physician podiatry division based in Hartford. This podiatrist will provide all aspects of podiatric care with a focus on wound and surgical care to a well-established patient base. We require PSR-36 training and bc/be. Competitive salary and productivity bonus, partnership opportunities, excellent benefits, and reasonable overhead. Please apply online or via our website , or fax your CV to 860-524-2653. No phone calls, please. EOE

ASSOCIATE WANTED - SOUTH JERSEY

Part time/ Full time Full scope, well established group practice located between Phila. and the Shore. Digital X-ray, EMR, Diag U/S. Prefer PSR 24-36 individual with several years previous experience but will consider the right recent grad. Must be willing and able to provide quality palliative and surgical care. Medicare and NJ Blue Shield provider numbers is a plus. Competitive financial and benefits package. E-mail resume & references to: Toetrukr@aol.com

EQUIPMENT WANTED – AUTOCLAVE/CHAIRS

Wanted to buy – Used New Style (not pressure cooker) desktop digital autoclave (e.g. Midmark Ritter) and 2 waiting room chairs. Call 212-724-4457 or e-mail frottenberg@juno.com

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

turn-key operation grossing $570,000 annually based on one full-time doctor; practice is in a growing retirement area in the center of the state. Option to purchase or lease real estate. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours, so it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725 for details and ask for Lee.

PODIATRISTS NEEDED – DALLAS/ FT WORTH – TEXAS AREA

Texas Home Footcare Associates, a podiatry exclusive company specializing in house calls and visits to facilities for the elderly, is looking to hire podiatrists. We are located in the Dallas area. Full and part-time positions are available. Immediate Openings Available. Must have a Current Texas license. Competitive Compensation Package. If interested fax curriculum vitae to 972 931-4819 or e-mail gjmdpm@tx.rr.com. For further information, call 972-380-8028.

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes.Top hospitals. Fax CV with references to 703-491-9994

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