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RE: CMS to Now Cover Obesity Counseling (Jon Hultman, DPM)

From: Robert Bijak, DPM

I would hardly call "walking to reduce obesity" a  medical solution, but an obvious layman's answer. Obesity is associated with systemic complications including cardiac ones. A patient shouldn't be told to walk (exercise) without a physician's examination of cardiac ability to do so. Podiatrists are NOT real physicians who are trained or licensed to make determinations of coronary safety.

Dr. Hultman's response is a simplistic one, demonstrating a lack of knowledge of the associated risks and complications of obesity. When his first patient gets an MI from being told to walk without appropriate coronary screening, a JD will show him the value of his DPM in obesity counseling. 

Robert Bijak, DPM, Clarence Center, NY,

Other messages in this thread:



RE: Podiatrists and Hospital Privileges (Barry A. Wertheimer, DPM)

From: Robert Scott Steinberg, DPM

With all due respect, Dr. Wertheimer, what problems are you talking about that need fixing by podiatric med-mal insurance companies? The only problems I see today are those caused by CPME, AACPM, and APMA. They allowed new schools to open and they knew or should have known that there would not be enough residencies.

Dr. Wertheimer, your voice seems to be more for division of our profession instead of unification. We don't need that.

Robert Scott Steinberg, DPM, Schaumburg, IL,



RE: Podiatrists and Hospital Privileges (Bryan C. Markinson, DPM)

From: Barry A. Wertheimer, DPM

I have agreed with your take on surgery vs. general practice for years. Prior to PICA accepting CA as a state to write insurance (approximately 30 years ago), I was brought up to Washington State to consult by another insurance company that was thinking of writing policies in CA. I recommended that they consider being the leader in writing exactly as you (Dr. Markinson) stated in your remarks...they would have the power of making this change in the profession by not insuring anyone for surgery beyond a basic level (i.e., forefoot) and only insuring those with verified training able to obtain insurance for more complicated procedures.

The profession would then regulate themselves in the exact manner you state the dental profession functions. If a podiatrist performed procedures that went beyond his/her training and insurance coverage, he/she would be in serious trouble. If a podiatric surgeon performed any service other than surgery, he/she would lose the referral base from those who were sending the patients.

Sounds like a simple solution to the

Barry A. Wertheimer, DPM, Southern Pines, NC,



RE: Recent PM News Quick Polls

From: George Jacobson, DPM

After viewing recent polls on the percentage of surgery and the types of case in our practices, one can only conclude that Vision 2015 is misguided. For some reason, the different long-term projects that have been initiated over the past 35 years get "engraved in stone" and are passed down to successive presidents and board members as something that they have to accept without change. They appear to go unchallenged. Can't anyone admit that the profession doesn't need all of its future practitioners to have a 3-year surgical residency?

What is even worse is requiring a residency for licensure. Aren't there any prominent current or past presidents and board members to challenge the wisdom of forcing this false "upgrading of the profession" on its new graduates? Or is their silence in this forum a passive endorsement? It is slowly degrading the profession and will eventually obliterate it from its original purpose to help patients with ALL of their podiatric needs. It appears from the recent polls that surgery is the smallest percentage of the profession's calling. 


The state boards should not have been influenced to limit licensure the way they have because of Vision 2015. Even though we each have a DPM degree, we all know that we practice within our individual experience. The hospital's delineation of privileges is where the limits are set for each member, not at the licensure level. Those who practice beyond their experience end up costing us all in the liability area. These residency requirements deprive the profession of its future. Shouldn't this "Vision" be rescinded? Shouldn't state boards reduce the stringent residency requirements?


George Jacobson, DPM, Hollywood, FL,



RE: Wart Treatments (Theresa M. Hughes, DPM)

From: Michael J. "Dusty" McCourt, DPM

In regard to cantharone, I obtain mine from a compounding pharmacy in Roseburg, OR and have even heard that the local compounding pharmacy here in Eugene does it as well. I, too, have had great results and happy patients with using it.. Here are the websites:

NW compounding pharmacy: 


Michael J. "Dusty" McCourt, DPM, Eugene, OR,



RE: Wart Treatments (Theresa M. Hughes, DPM)

From: Kevin A. Kirby, DPM

I have been using Falknor's needling method both for solitary and mosaic verrucae quite successfully now for the past 20 years.  The late Gordon W. Falknor, DPM, first described this "needling method" for verrucae plantaris treatment in "Falknor GW: Needling-a new technique in verruca therapy: a case report."  JAPA, 59:51-52, 1969.


Falknor originally described his needling method to offer the following advantages:


1. A minimum of time is required to perform this technique.

2. A minimum of material (anesthetic, syringe, dressing) is employed.

3. There is a minimum of post-operative pain.

4. A minimum of bandaging and dressing is needed.

5. A minimum of post-operative calls are required.

6. No ulceration, infection or scarring results.

7. The patient may continue to bathe as usual.

8. There are no restrictions on work or athletic activities.

9. There is a low rate of recurrence.


These have also been my clinical observations in the numerous times I have performed his technique on my own patients over the past two decades.


A more recent study of 45 patients was just published a few months ago in the Journal of Clinical Medicine that showed a 69% resolution of verrucae following needling treatment (Longhurst B, Bristow I:  The treatment of verrucae pedis using Falknor's needling method: A review of 46 cases.  J. Clin. Med. 2013, 2, 13-21: doi:10.3390/jcm2020013).


Kevin A. Kirby, DPM, Sacramento, CA,



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: Todd Lamster, DPM

First, to those who don't believe in its utility, have any of you used an ultrasound machine for guidance during an injection? What is your experience that leads you to believe that you don't need it?

I used to be in that camp and thought the same thoughts, and figured that if I can't inject the fascia or a joint by now, I should be doing something else. Wrong! I know anatomy as well as anyone else, and I can tell you...

Editor's note: Dr. Lamster's extended-length letter can be read here.



Make the Most of Every Day

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1. Work. Map out your top three work priorities for each day. Rae sometimes maps out her entire week on a Sunday if her priorities are clear. However, you can map them out on a day-to-day basis. Just make sure you start every day with a clear list of must-dos.

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Source: Adapted from “How to Schedule Your Day for Peak Creative Performance,“ Amber Rae, Fast Company via Communication Briefings.



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: Neil H Hecht, DPM

The injections I give to the foot and ankle were taught to me without ultrasound because it didn’t exist during my training. While therefore anecdotal, it would seem that my technical competence is validated by the results of these injections. Local digital blocks and PT blocks yield obvious and verifiable anesthesia and vasomotor changes. Calcaneal nerve branch blocks yield heel anesthesia prior to “heel spur” injections. When done without branch blocks, medial approach and occasional plantar approach heel injections of corticosteroid/local combinations yield immediate pain relief from the field block and reported relief of plantar fasciitis of approximately 60-90%, on average, at most one week follow-up appointments. Intra-articular injections yield immediate verifiable results as well with relief of joint pain on the post-injection exam within minutes. Extra-articular injections such as anterior talo-fibular ligament or neuroma injections seem to be similar with virtually immediate pain relief on post-injection examination.


Casual discussions with peers reveal similar information. Perhaps this is because my peers have also been taught without the assistance of ultrasound guidance. Some of my peers do use ultrasound for diagnostic assistance and/or verification. I am curious if the training today, or in recent years, includes and/or mandates the use of ultrasound for injection guidance. Also, what do the podiatrists do in the operating room if they rely on ultrasound guidance in the office? I have not seen ultrasound imaging apparatus in any of the hospitals in which I perform surgery.


Neil H Hecht, DPM, Tarzana, CA,



RE: Diagnostic Ultrasound (Bryan Markinson, DPM)

From: Robert Kornfeld, DPM


Bryan Markinson states a case of ultrasound abuse which has nothing at all to do with efficacy of guided injections. This simply sounds like an unethical doc. Guided injections have their place in our armamentarium. There is no shortage of journal articles supporting its use. I have found it to be extremely helpful in injection placement and efficacy (although I do not inject cortisone into ligaments, tendons, or joints). Realize that if your injection is not in the right place or the right plane, no amount of "diffusion" is going to get it there. My fellow podiatrists should also know that guided injections are becoming the gold standard in radiology, rheumatology, orthopedics, etc. It should be in podiatry as well. Why rely on hit or miss when you can clearly see where you need to be?

In the same vein, why should we do minimally invasive fluoroscopic or endoscopic procedures? Let's just put the knife in and slash around. We're bound to be right half of the time.

Robert Kornfeld, DPM, Manhasset, NY,



RE: Diagnostic Ultrasound (David E. Gurvis, DPM)

From: Bryan Markinson, DPM

Drs. Gurvis and Foreman take my research idea and interpret that my intention is to prove that ultrasound use is fraudulent or somehow unethical, or even unnecessary. Nothing could be further from the truth. However, I will never be convinced that the majority of current users are adequately trained in musculoskeletal ultrasound in proportion to its frequency of use.

Bryan C. Markinson, DPM, NY, NY,



RE: Diagnostic Ultrasound (David Samuel, DPM)

From: Martin Wendelken, DPM,

It is totally clear to me that there are a number of podiatric physicians who do not understand the capabilities of diagnostic ultrasound. For example, 1) there are many patients who have heel pain where the plantar fascia is torn and injection is contraindicated or 2) there is a tendonopathy, where partial tears exists, or 3) there are swellings where a tumor resides. For those who feel that it is only a financial incentive, I need to state that they are misdirected. The instrument is only as effective as the capabilities of the user.


Martin Wendelken, DPM, NY, NY,



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: David E. Samuel, DPM

In years of reading PM News, I perhaps wrote in once or twice, but some of this makes me crazy. Here we go again. Many roundabout comments and thoughts on ultrasound-guided foot/ankle injections. Nice cordial dialogue. On the other hand, I will get to the point. Are you kidding me? Do you really think those using this modality to inject a plantar fascia have fooled the insurance companies that they will keep paying it. If so, I have some prime beach front property in Arizona for sale.

This is clearly all about the Benjamins (really the Lincolns, working down to the Washingtons)  Everyone knows it. It's okay. Go ahead and admit it. But please don't insult everyone's intelligence to justify it. I bet this will soon be completely removed from payment. I even heard someone tell me they used it to inject neuromas! I may not be the sharpest knife in the drawer, but really? Does anyone really need any help learning how to inject a plantar fascia or an ankle joint without the use of an ultrasound machine? It would be my pleasure to give a quick tutorial. Or even better, I could ask one of our first year resident to demonstrate.

If those of you who have talked themselves into believing U.S. is needed to properly put a 25g 1.5" needle into the plantar medial heel, I would not tell the graduates looking for programs where your offices are, as around the corner may be a good place to open shop. For spinal injections, it's a totally different ball game. 

David E. Samuel, DPM, Springfield, PA,



Diagnostic Ultrasound (David Secord, DPM)

From: Elliot Udell, DPM


The paper quoted by Dr. Secord states that ultrasound guidance significantly improves the accuracy of joint injection, but ultrasound guidance did NOT improve the short-term outcome of joint injections.


What is significant to this discussion is that the joints studied in the above paper were knees, hips, shoulders, and ankles. These are much larger areas of the body where it may be less likely for small amounts of 
injected fluid to spread out on its own. Nevertheless, even with large anatomic areas, using ultrasound did not improve short -term outcome of joint injections. 

I have just begun to use ultrasound, but cannot swear at this point in time that my injections done without ultrasound were in any way inferior to those done with ultrasound. A strong motivator for me to institute ultrasound-guided injections is that, because so many of our colleagues (podiatric, orthopedic, and rheumatologic) are using ultrasound, many of my patients have told me point blank that they would not allow me to give them an injection unless I used ultrasound. Articles such as the one quoted by Dr. Secord would not sway their opinions. Hence, I bit the bullet and bought the least expensive ultrasound on the market, but one with a very good training package and support.


Elliot Udell, DPM, Hicksville, NY,



RE: Diagnostic Ultrasound (Bryan Markinson, DPM)

From: Martin E. Wendelken, DPM, Bill Greco, DPM

The use of diagnostic ultrasound in the identification of tumors on any location of the foot should not be understated. I have identified 4 malignant soft tissue masses that appeared to be “ganglions”, some of which were injected by others thinking they were ganglions. Therefore, all soft tissue masses are examined using diagnostic ultrasound before we inject or aspirate them.  

One oncologist unfortunately stated to one of the referrals that injections into tumors can complicate treatment and may cause spreading of the cells/mass (causing legal issues for one of the podiatrists). This technology can improve patient care, however, it is clearly operator-dependent. As far as guided injections, sonography can allow for exact placement of injectable medications in the area where the pathology is located as determined by the US exam. We have found, in fact, that this reduces the number of injections to achieve a satisfactory result. 


Martin E. Wendelken, DPM, RN, NY, NY,

Is the example of ten ultrasound-guided steroid injections an example of the fallibility of ultrasound or the incompetence of care, bordering on malpractice, of one individual?

Ultrasound as a practice adjunct will provide the practitioner valuable information. Is the mass cellular or fluid? Is it lobulated or a single chamber? Are there extensions of the mass beyond...

Editor's Note: Dr. Greco's extended-length letter can be read here.



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: David Secord, DPM

Here's a relevant article on this topic: "Ultrasound Guidance for Intra-articular Injections Improves Clinician Accuracy" Arthritis Rheum. 2010;62:1862-1869.


The use of ultrasound guidance has been advocated as a technically superior method for performing intra-articular injections. This study compared clinical efficacy and technical accuracy in 184 patients who underwent either ultrasound-guided intra-articular injections or blind injections.

One third of blind intra-articular injections were found to have been inaccurate. Moreover, injections performed by a trainee rheumatologist using ultrasound guidance were shown to be more accurate than those performed by more senior rheumatologists performing blind injections.

No significant difference between the two groups was noted in the clinical outcome measures used (Visual Analogue Scale, modified Health Assessment Questionnaire, and the EuroQol 5-domain questionnaire, erythrocyte sedimentation rate and C-reactive protein levels), except for an improvement in Visual Analogue Scale joint function scores in the ultrasound-guided injection group at 6 weeks.

David Secord, DPM, Corpus Christi, TX,



RE: Diagnostic Ultrasound (Bryan Markinson, DPM)

From: Lloyd S. Smith, DPM

Dr. Markinson makes a great comment about ultrasound-guided injections. I offer the following: if an injection using ultrasound paid at virtually the same rate as without U.S., what would you do?  What is the intrinsic work value of using an U.S. machine? Do you need a dedicated room to perform the U.S. component of the procedure?

Is it about the benefit to the patient or the reimbursement? In any and all cases, the benefit of a procedure to a patient is the key component to its worth. I am also quite certain that in the near future, the value of an injection with or without U.S. will be similar. Will this alter your treatment rationale, the use of the U.S. machine, and/or the purchase of one?


Lloyd S. Smith, DPM, Newton, MA,



RE: Maximalist Running Shoes are In, Minimalist Running Shoes are Out

From: Kevin A. Kirby, DPM

I just wanted to clarify a point that I made in my recent posting about the new "maximalist" running shoe, the Brooks Transcend. The Brooks Transcend was "unveiled" at the Outdoor Retail Summer Market trade show held in Salt Lake City on August 1, 2013. However, the Transcend won't be on store shelves until February 1, 2014. The maximalist running shoe, Hoka One One, has been on specialty running store shelves for three years. Sorry for any confusion this has created.


Rumors also have it  that many of the major running shoe manufacturers will be introducing new "maximalist" running shoes in 2014. Much of running shoe manufacturers' ability to design thicker, more cushioned, yet relatively light running shoes seems to be due to the recent development of newer midsole materials that allow these new running shoe sole constructions to occur. It is an exciting time in the history of running shoe development that every sports podiatrist should try to stay abreast of.


Kevin A. Kirby, DPM, Sacramento, CA,



RE: Diagnostic Ultrasound (Bryan Markinson, DPM)

From: Michael Forman, DPM, David E. Gurvis, DPM

It is no wonder that Dr. Markinson wonders about the fluid injected in a plantar fascial treatment. I wonder as well. However, the first scenario deals with someone who injected a dorsal ganglion ten times. Now come on Bryan, that is not the  fault of an ultrasound machine. The doctor was obviously a goof ball.

Michael Forman, DPM, Cleveland, OH,

Regardless of the utilization of ultrasound or not, 10 injections of a steroid into a ganglion cyst seems to fall beneath the standard of care. I think that is the issue here, rather than the use of ultrasound, which is peripheral. As to Dr. Markinson's musings about how much steroid would remain in the body of the plantar fascia, I “guess” that it is mostly due to the nature of the structure, but I cannot, of course, prove it. Your study would be most interesting if indeed it could be accomplished morally in a manner where it could be measured.

If a new technology comes along, and...

Editor's note: Dr Gurvis' extended-length letter can be read here.



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: Bryan C. Markinson, DPM

I recently treated a patient who had 10 ultrasound-guided injections of steroid into a golf ball size ganglion on the dorsum of the foot. The patient came to me when he woke up one morning with a red, hot oozing mass of necrosis requiring surgical debridement. This is an example of clearly inappropriate use or worse of this modality.

We all know those common ganglions on the dorsum of the foot. If you need ultrasound to inject it, you shouldn't be treating the patient in the first place. Also, it may be prudent to establish the diagnosis before committing your patient to such an assault. A simple aspiration with cytology would document that you are actually treating a ganglion. Malignant fibrous histiocytoma, no stranger to the foot, looks just like a ganglion. But that is for another day. I have another question regarding the ultrasound-guided technique for plantar fasciitis. After the proponents do what they claim is a far superior injection than that without ultrasound, what happens to the fluid injected when the patient gets off the chair and bears weight on the heel for the rest of the day or night?

I would welcome a study where radiopaque dye was injected to show that whether you use ultrasound or not, in a few minutes of weight-bearing, what happens to that fluid? Does it stay where you put it? Or does it diffuse around to the points of least resistance, making the use of the guidance moot. I wonder.

Bryan C. Markinson, DPM, NY, NY,



RE: Obtaining Reports from Uncooperative Specialists (Elliot Udell, DPM)

From: Paul Kesselman, DPM

Elliot's remarks are unfortunately becoming more and more true. In speaking with a Medicare official, I was advised to try the following:

1) After you have exhausted the usual letter-writing and requests, get your patients involved and have them sign a records release;

2) If that does not work, have the patient (if possible) go the physician's office and demand a copy of their record;

3) If that fails, threaten the practice with notification that you will be notifying the state (or municipal) board of medical practice and the state's Attorney General's Healthcare Fraud Bureau.

I have usually had to resort to #1 and #2. I've only had to resort to #3 verbally, and that was with the staff who then referred me to the doctor himself. Then the records were magically produced (unfortunately in that case the record I needed was unintelligible and of little use). Bear in mind, for the most part, most physician practices are usually pretty compliant.

Paul Kesselman, DPM, Woodside, NY,



RE: Maximalist Running Shoes are In, Minimalist Running Shoes are Out

From: Kevin A. Kirby, DPM

Over the last five years, there was a rise in interest in barefoot and "minimalist" running, along with an increase in runners getting injured by trying to transition into barefoot and/or minimalist shoe running. Two years ago, here on PM News, I mentioned a new shoe that I had run in, the Hoka One One, which I had thought represented a new design breakthrough and a new shoe category, the "maximalist shoe".  Hoka One One running shoes have much thicker and more cushioned midsoles and have become increasingly popular, especially in the ultra-marathon and trail running community.


Recently, other running shoe manufacturers have taken notice of the popularity and success of the Hoka shoe and are now jumping on the "maximalist shoe bandwagon" with their own form of thick-soled, highly cushioned midsole running shoes. Most notable in this category is the newly released Brooks Transcend shoe, which has a much thicker, cushioned midsole, like the Hoka.


At the same time, minimalist shoes, such as the Vibram FiveFinger shoe, are on closeout specials throughout the country as runners are increasingly voting with their feet and wallets to move away from the much-hyped, questionable benefits of barefoot and minimalist shoe running. I suggest all podiatrists who do treat runners to go to their local specialty running shoe stores and inspect and test-wear both the Hoka and Brooks Transcend running shoes that will likely represent the latest trend in running shoe design: the maximalist running shoe.


Kevin A. Kirby, DPM, Sacramento, CA,



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: Andrew Cassidy DPM, MS

I am wondering why some of our colleagues are against making more money while at the same time ensuring that the injection they are giving (blind if not using ultrasound) is in the proper location. Ultrasound is a wonderful tool that I use for much more than plantar fascial injections. I have used it to find foreign bodies that do not show up on x-ray, evaluate soft tissue tumors, and to evaluate the healing of fractures, which is often better than x-rays which lag behind compared to ultrasound. Increased revenue and decreased liability are all good things. How do you know that the medial fascial band doesn't have a partial tear? Do you really want to inject a partial tear and try to defend it later in court without an ultrasound study to support your reasoning for an injection?

I think that in our current medical environment, we should not be worried about using a valid modality to help ensure we give accurate care to our patients. The last time I checked, insurance companies were not going out of their way to increase our reimbursements. This is a wonderful diagnostic tool, and the patients like the technology. Patients will actually be engrossed in watching the screen on the ultrasound and not dwell on the pain of the injection. Use the ultrasound, inject the patient, and bill it out! It is good for you and the patient.

Andrew Cassidy DPM, MS, Austin, TX,



RE: Hill Podiatry Chairs (Marc Katz, DPM)

From: Richard Rettig, DPM

I have had a Hill chair for about 20 years. It is a very basic chair at a reasonable price. I had my concerns originally about some ergonomic minor issues (switch placements and footrest length) that were changed by the company for my chair at my request, and I felt they should have  adopted these changes for all their chairs, and stated it publicly in the past.

Recently a +500lb patient (above the chair-rated capacity) damaged the frame of my chair which,  in turn, ruined a motor, too. This was well beyond any warrantee. The company picked up my chair (I am within 50 miles of their plant) and fixed it in-house and returned it, re-welding the frame and replacing the motor. They refused payment for this. I need to now publicly commend them for their service.

Richard Rettig, DPM, Philadelphia, PA,



RE: Diagnostic Ultrasound (Michael Forman, DPM)

From: Ivar E. Roth DPM, MPH


Generally speaking, getting a 90% success rate with an injection, as Dr. Forman writes, would be considered excellent, however to ultrasound everyone and bill for it under these circumstances is an example of overuse. If you feel that you need to get 100% accuracy with every injection and use ultrasound, why make 90% of your patients (and thus the insurance companies) pay for unnecessary services?

If you feel you need to use an ultrasound to give an injection, do so but do not charge the patient or the insurance company, or bill for those where it actually helped, i.e., the 10%. In summary, if you choose to give a shot and need assistance, that is your choice in providing better care, not a requirement, and so ultrasound should be included in the shot charge. As podiatrists, we cannot think, "Oh, I saved the insurance company $2,000 for an MRI" to justify using ultrasound on every patient who requires an injection."


Ivar E. Roth DPM, MPH, Newport Beach, CA,



RE: Recommendations for Securing Small Business Loans (Daniel T. Hall, DPM)

From: Andrea Simons, DPM


Three years ago, I started my own practice after spending one year out of residency with another group. To secure my start-up business loan, I went to multiple local banks to get interest rate quotes and the requirements necessary for their bank/credit union. For a start-up loan, I needed 1:1 collateral to secure the loan, and since I had recently just finished residency and had a large amount of school loans, I did not have the 1:1 collateral necessary. My parents had to co-sign on the loan with me in order to secure the loan. 

I also had a very detailed business plan to show them how I planned on repaying the loan and what I projected the practice to bring in for the next 3 years. I did figure in a salary for myself (very modest and just enough to live on) and $50,000 of working capital. I was surprised how long it actually took for the money to actually start coming in, and all of the little expenses that I did not expect when I started the practice. 

I would be happy to talk to anyone who is looking at starting/buying a practice and to give any tips/advice that I can. Although it was a lot of hard work, it was very much worth it!

Andrea Simons, DPM, Dewitt, MI,

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