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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,

Other messages in this thread:



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

From: Kathleen Neuhoff, DPM

If at all possible, secure your loan with a local bank that does not "sell" its loans to others.  Be sure you bring to the bank a viable business plan. There are numerous books with templates for producing a plan, and banks will expect that you will be able to show them how you plan to repay their loan and meet your other expenses at the same time.  

Be sure to borrow enough money. Remember to account for your living expenses and remember that most new businesses (even practices) take three years to become profitable. Don't forget to get a line of credit for your new business. There WILL be unexpected expenses!

Kathleen Neuhoff, DPM, South Bend, IN,



RE: Inexpensive Cast Cutter (Tom Fitzsimons)

From: Marc Katz, DPM

I believe that we use many products and pieces of equipment that may not be FDA regulated. One example that may be similar is that many DPMs use Dremel drills for various purposes. Some even connect bone cutting burrs to them. This is much more invasive than a cast cutter. In addition, most podiatrists who have a cast cutter probably have one that is way beyond its prime. They are like tanks and last forever. My cast-cutter was from a hospital and was made in the '80s. As a professional, I have chosen to use it because I have determined that when used properly, it will cause no harm to my patients.

I also believe that my malpractice carrier does not state what I can and can't use in my practice. Could you please produce a statement from PICA and other carriers stating that they would not cover us if we use a multi-tool. I believe I would use a multi-tool if I had the facts. My patients don't judge me by my tools! They trust me based on my care and competence.

The most regulated equipment or medication in the hands of an incompetent or inexperienced doctor or staff member can be disastrous. So I don't buy the argument. It would be great if some of the attorneys in the group could weigh in.

Marc Katz, DPM, Tampa, FL,



RE: Medicare Calling Patients

From: Name Withheld (FL)

I had the situation of a patient presenting to me with no fungus toenails who had not used any medication ever to treat fungus toenails and does not meet Medicare criteria for routine foot care; however, she states that she has been under the active care of a podiatrist for the past two years, and the podiatrist trims her toenails and gets paid by Medicare. I asked her to provide me with records of the previous podiatrist's treatments, and to my surprise, she delivered to me a computer printout of all of her charges. There were twelve charges, each was 99213 and each had the diagnosis of 703.8 only. It is my guess that it is billing such as this that is getting the attention of the Medicare auditors.

Name Withheld (FL)



RE: How Do Doctors Get Paid (Bret Ribotsky, DPM)

From: Robert Gjertson, DPM

The author could have gone a little further in his analogy. The second party at the table, because the same dinner was ordered, only paid 75% of the allowable amount. His guests, the third and fourth diners at the table, only paid 50%. So, the owner ends up losing money each time he serves a meal.

Robert Gjertson, DPM, Saint Paul, MN,



RE: Podiatry's Secret Problem (Steven Moskowitz, DPM)

From: Victor S. Marks, DPM, MPH

A 90 year-old woman with diagnosed dementia, requiring placement in an assisted-living facility, should be eligible for podiatric care every 61 to 90 days without question. I think our energy would be better spent trying to have current Medicare guidelines revised to better meet the healthcare needs of an aging population with multiple chronic diseases who can no longer safely care for their feet. We are still the only profession qualified to provide this much-needed care.


Victor S. Marks, DPM, MPH, Scarsdale, NY,



RE: Podiatry's Secret Problem (Michael J. Schneider, DPM)

From: Robert Kornfeld, DPM

Dr. Schneider's assessment of inappropriate billing may be correct in his experience; however, here in NY, when I was in the Medicare program, I had very few non-covered routine care patients simply because it was too easy for them to find podiatrists who billed for a covered service instead. I have had some of my "snow bird" patients come back from Fla. to show me EOBs from DPMs who assured them that Medicare pays and collected (not billed) hundreds of dollars for a visit in which nail and callus debridement was performed. I believe this is a pervasive problem and is going on in more offices than we would like to admit.

Robert Kornfeld, DPM, Manhasset, NY,



RE: Podiatric Certification of Nail Techs (Jeanine Jones Moss, DPM)

From: Robert Spalding, DPM

In response to the query on medical nail technicians or MNT™, a more accurate depiction is that for the past 6 years, there is an extensive proprietary online course certification through that a licensed nail tech can complete. This course culminates with a one-week podiatric internship that instructs nail technicians to be trained to work under the podiatrist’s direct auspices to do routine foot care, perform medical pedicures, or work as a PMA (podiatric medical assistant).


Robert Spalding, DPM, Signal Mountain, TN,



RE: Alternative to Hydrisonol Lotion Pump (Michael Forman, DPM)

From: Arthur Gudeon, DPM

Obviously, there are many options out there for dry skin care, but just on a personal basis, my favorites to dispense for my patients for many years have been two products by Gordon Laboratories. One is Emollia-Lotion, because its price to the doctor is very reasonable, and the patients like the fact that it absorbs in easily and isn't greasy.

The other, which I use at least as frequently, is Aloe Grande Lotion, which contains high dosages of Vitamins A & E plus aloe vera gel, and besides being a great lubricant is also a healing agent which I use after surgeries and over scars. It also comes in creme form, but I prefer the lotion's pump dispensers, which the patients find easier to use. My patients often come by the office just to purchase refills.

Arthur Gudeon, DPM, Rego Park, NY,



RE: Employment Advertising (Joel Lang, DPM)

From: Thomas E. Silver, DPM

I agree with Dr. Lang regarding contracting a local medical assistants school if there is one located in your community. I have a good relationship with the extern director at a local school and regularly get MA students who do a 2-month externship (without pay) in my clinic. We interview them initially similar to any regular job applicant, and only select the best ones. I have hired several of these students over the years after they completed their externships. Most will work very hard and really help out during their two months, even if they don't work out as employees.

The most important recommendation I can make is to contact Jay Henderson at Real Talent Hiring ( before you hire anyone.

Thomas E. Silver, DPM, Golden Valley, MN,



RE: Efficacy of Compounded Drugs (Allen Jacobs, DPM)

From: Bryan C. Markinson, DPM

I am not shocked and dismayed at the tone of Dr. Allen Jacobs' response to my inquiry as to the standards and practices for compounding pharmacists. After all, he has growled at me in this forum before! In no way did I portray the practice as a "free for all" and I certainly did not indict any such compounds as witches brews.

I never mentioned the FDA, and never compared any compounded product to that of the "products or therapies endorsed by Dr. Markinson in his lectures." That, in my opinion, was a very cheap shot. In fact, my query, if anything, elevated...

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



RE: Efficacy of Compounded Drugs (Bryan C. Markinson, DPM)

From: Ed Davis, DPM

I have utilized compounded topical medications for a number of years. Traditionally, it had been incumbent on the practitioner who ordered the compound to specify the active ingredients as well as the carrier, along with the description as to how the medication is to be formulated. One needed to use knowledge of pharmacology and physiology, measure patient response, and utilize a process which included some "trial and error." That process may be considered at odds with current methodology. The individual compounding pharmacists would often share experiences and expertise.


That process has changed in recent years as compounding pharmacies have, in a number of instances, metamorphasized into mini-pharmaceutical companies. Such pharmacies create lists of "suggested" compounds to practitioners and are actually marketing such formulas with "suggestions" as to their intended use. The line between traditional compounding and pharmaceutical manufacturing is becoming blurred. Additionally, compounding pharmacists, are creating pharmaceuticals of which there are shortages. It is not clear, based on that role, where one actually becomes a manufacturer. Dr. Markinson appears to be discussing the traditional concept, but Dr. Jacobs, the latter concept.


It is my hope that self-regulation can continue to be effective in this industry as compounding pharmacists have played a vital role in filling of niches not addressed by big pharma.


Ed Davis, DPM, San Antonio, TX,



RE: Displaced MBA Implant (Louis W. Nordeen, DPM)

From: David Secord, DPM

As the MBA (or any other arthroereisis implant) doesn’t occupy or involve the STJ, why would you do an arthroscopic procedure there? What indication is there to violate a joint without radiographic indications of osteoarthritis or pathology? Did you mean to ‘scope’ the sinus tarsi? If so, wouldn’t that disrupt the very fibrotic tissue and remodeling of the area which would make the need for the implant moot? I’ve also taken out my fair share of these, done nothing else other than some physical therapy, if indicated, and they do fine. I’d have to see some stats on this to be convinced it is unnecessary.

David Secord, DPM, Corpus Christi, TX,



RE: Efficacy of "Pain" Creams

From: Kathleen Neuhoff, DPM, Matthew Roberts, DPM

I have used compounded topicals with DMSO, tetracaine, and betamethasone for many years and have found them very helpful for localized problems such as neuritis. I do not use them for long-term because the steroid can thin the skin and the DMSO can become irritating, but they have been very helpful to provide immediate relief while the underlying problem is addressed and resolved.

Kathleen Neuhoff, DPM, South Bend, IN,

Other than counter irritants or capsaicin, what is the mechanism of action of these products? As I recall, narcotic analgesics work on opiate receptors in the midbrain. Are there any such receptors in the PNS that these narcotic compounds work on? If not ,what is the efficacy of applying these compounds locally?


Matthew Roberts, DPM, Miami, OK,