The Voice of Podiatrists

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February 02, 2007 #2,800 Editor-Barry Block, DPM, JD

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Heelys Can Contribute to Serious Injury: IL Podiatrist

If something calls for a helmet, take it as a warning sign, Dr. John Grady says. You won't catch any of his four kids wearing Heelys. "To encourage it is a big disservice to kids," he said. Grady is board certified in podiatric surgery, podiatric orthopedics and wound care; chief of podiatry at the Veterans Administration Chicago Healthcare System; and scientific chairman of the Midwest Podiatry Conference, one of the largest podiatric conferences in the nation.

Dr. John Grady

Although the walking-rolling mode with Heelys is rudimentary, Grady said the wheeled shoes can contribute to serious injury because they go against nature. "The part of your walking that's least stable is when the heel is going from up to flat," he said. That instability is then hindered further by putting all of your weight on one heel -- and one wheel -- and keeping your toes lifted upward to continue rolling. "The tendons in the front of the foot are not made to lift your foot up" for an extended period of time, he said.

Heelys may result in shin splints or torn ligaments, which can require a cast. The latter was the case with one of his young patients recently. Ligaments, especially in growing teenagers, do not heal as well as bones, Grady said. One-third of all active skateboarders can bank on being injured, he said, and Heelys may be on par with or worse than skateboards. "You'd be way better off with skates" that have wheels front and back so the foot is flat and stable, Grady said.

Heelys even made the World Against Toys Causing Harm's 2006 "10 Worst Toys" list, citing the serious risk of head or spinal injury.

Source: Vickie Snow, Daily Southtown. [1/31/07]

CA Podiatrist Finances TV Pilot

After years of men getting a bad wrap in television and movies, the guys of “Manhattan Beach 101” want women to know that men have feelings too. And they hope that the show will do for the brewskie what “Sex and the City” did for the cosmopolitan. Hank Cohen, the former president of MGM television partnered in the show’s creation with Allen Selner, a podiatrist and Manhattan Beach resident who financed the project. Selner wanted to use his money and knowledge for good, so he created an educational television show about hot guys looking for hot girls (with character) in the hot town of Manhattan Beach, CA.

Dr. Allen Selner

Attempting to heighten cultural awareness, Selner and Cohen joined forces once before on a radio talk show called “The Men’s Room” in 1996. What they gleaned from that experience was that women really do not understand men. Selner wants to change that. He wants the two sexes to start over, scrap the stereotypes and reach a new level of understanding. To tackle this endeavor, Selner chose the medium of television, putting into high definition what he sees on a daily basis: eligible single men bar-hopping around the sexy streets of downtown Manhattan, struggling to find really great women.

In the television show, which the crew shot over six 15-hour days at various locations in Manhattan Beach, Selner plays both the narrator and the big brother to the hunky guys who are struggling to find the perfect girl. It’s difficult, as you’ll see, in Manhattan Beach, because the sea of women seems to be strewn with mines of deception.

Now that the pilot has been shot, edited and set to music, the real work begins: impressing network executives. Cohen and Selner plan to shop the show around, hoping for a bite so that the story lines of these men in the beach city can have the chance to evolve.

Source: Lisa McDivitt, Hermosa Beach Easy Reader [1/29/07]

FDA Outlines Safety Initiatives

FDA officials promised a new commitment to safety and a pledge to work with the Veterans Health Administration to share information on drug and device safety. FDA Deputy Commissioner and Chief Medical Officer Janet Woodcock noted how the new approach will make better use of new science and technology and how a new understanding of "the molecular mechanisms of adverse events" will allow for the screening of harmful compounds so they never get put into drugs in the first place or will help identify those who are most at risk from a negative reaction to those compounds. This approach, she said, will allow the FDA to go from just counting side effects of new drugs to actually preventing and controlling them.

Sens. Edward Kennedy (D-MA) and Mike Enzi (R-WY) are expected to introduce a bill to overhaul the FDA’s drug safety operations, and Kennedy released a statement indicating that the FDA’s actions won’t alter his course.

Source: Andis Robeznieks, Modern Healthcare [1/31/07]

Query: Boxing Shoes

I have a patient who is a boxing coach and requests the names of boxing shoes that he could suggest for his boxing pupils. Other than the general features which I emphasize for my athletes, I am not aware of specific boxing shoes or references that feature surveys of boxing shoes. Please advise.

Alex Kor, DPM, MS, Temple Hills, MD

RE: Circulator Boot
From: Paul Kesselman, DPM

I know of a few DPM's who swear that the circulator boot does work miracles. They have had success with this product where bypass is not an option and the only other solution is amputation. These doctors bill their patients cash because they know Medicare doesn't cover this therapy. One cannot condone billing Medicare for a non-covered service covered service coding. If these allegations are proved true, restitution is in order.

I do, however, strongly object to the phrases "non traditional" and "non-podiatric" treatments. On what basis do prosecutors claim this to be non-podiatric and/non-traditional? Are only covered services traditional? Certainly any service rendered to a foot condition could be considered podiatric treatment. Would anyone suggest that foot orthotics or latex shields are non-traditional or non-podiatric?

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

RE: Patient Rejects Potential Surgery (William Axton, DPM)
From: Multiple Respondents

My advice to Dr. Axton, DO NOT perform the surgery. From what you describe, the planned procedure is appropriate. Do not let any patient talk you into or out of any surgery. You are the one who went to medical school, not them. Without performing the 1st metatarsal osteotomy, you are setting yourself up for failure. The patient will be unhappy and then guess what, her orthopod boss is going to perform the surgery after the fact and you're going to get a subpoena for all sorts of nonsense.

I was talked into changing a procedure when I first started. Despite the patient being happy, I was unhappy. The x-rays and foot are not optimal and definitely not a reflection of my capabilities. There is plenty of work out there for you to reject this patient. A good night’s sleep is worth a lot more than the $500 you're gonna get for the hammertoe repair.

Eugene A. Batelli, DPM, ebatelli2001@yahoo.com

As a resident, my director's practice had a good amount of redo work and second opinions. Isolated 2nd metatarsal Weil osteotomies without fixing the hallux valgus deformity work "sometimes." In my brief, albeit busy six months of practice so far, I've had the opportunity to correct three patients who presented with this problem.

Your issue isn't the surgery itself. Your issue is that you need a better patient - preferably someone who trusts your judgment and skills. I would encourage a second opinion, and in my own practice, I would likely not operate on this patient. Your best case scenario at this point is that she has her surgery, gets a perfect result from a procedure you don't believe in, and thus you have "tied" the doctor she used to work with. Anything less than perfect, you get, "Maybe I should have gone to the foot and ankle orthopedist, and not the podiatrist."

Eric Edelman, DPM, ericedelman@gmail.com

The difference between the surgical treatment plan that you are recommending and what the patient is willing to accept is potential long-term outcome. Both procedures will give the patient short-term relief of her symptoms. What you are concerned about is your ethical commitment to doing a procedure that will be complete and will stand the test of time. On the other hand, there is longer healing time with the osteotomy, more pain and more risk. The patient is aware of all of the pluses and minuses since she worked for a foot and ankle surgeon for twenty years.

What we have to face is that it is her foot and she is the one making her own life decisions. If the scaled down set of procedures she is willing to accept will give her temporary but not necessarily permanent relief, spell that out both verbally and in writing. Make sure she understands your point of view and signs a document saying that she understands it. The obvious other problem is what Dr Block alludes to. Is she is going to two surgeons for opinions and are both from different schools of thought? If so there could be possible problems for you especially in the post operative period. Will the patient have the level of trust when she is having post operative pain to trust your clinical judgment or will she run to another surgeon who may be hostile to you or just have a different way of approach if she is having discomfort?

I tend to think that she will have the level of trust because in her 20 years with the other doctor she most likely encountered patients who had complications as a result of doctor hopping in the midst of a treatment plan. In any case this should be carefully assessed before bringing her into the operating room.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: 10 Year Old Toe-Walker (Charles T. Martin, DPM)
From: Multiple Respondents

I have an autistic (Asperger's Syndrome) 14 year old son. My son was also a toe-walker. He could get down on his heels when instructed, but would shortly thereafter go back up on his toes. I believe, in his case, the toe-walking stemmed from his tactile defensiveness, with the heel strike producing a disagreeable sensory input.

After failure of attempted desensitization with brushing techniques, AFO's, gastrocnemius Botox injections with serial casting and night splinting, my son continued to toe-walk. At 12 years of age, my son underwent bilateral TAL. Believe it or not, he managed to toe-walk in the casts. After removing the casts, the toe-walking was eliminated.
My son is now 14. In retrospect, I would have gone with the TAL sooner.

John P. Miller, DPM, Olean, NY, cmille123@aol.com

I have indeed seen this a number of times and most of the time it is some habitual and benign condition. But you must thoroughly workup the patient for neuromuscular disease, especially Charcot-Marie Tooth peroneal muscle atrophy, spastic diplegia, spastic triceps. According to Tax's book Podopediatrics, "The child must be thoroughly examined."

Jim Fisher, DPM, Eureka, CA, jimf@humboldt1.com

Toe-walking is well documented in the autism community. The prevailing theory is because of their hyper aesthetic state they do not like the ground reaction of the heel strike. Due to this same reason, they squint when outdoors and try to cover their ears when mildly load noises are present. You can probably contact Cure Autism Now for more info.

As to how to treat the child, silicon heel cushions are probably the best course of treatment, to reduce ground forces at heel strike.

Albert Nejat, Culver City, CA, TheDoctor@AlbertNejat.com

I posed the question to my daughter, who is a pediatric occupational therapist in Northern VA...her brief response:

Changing the toe-walking habit is really difficult if possible at all. There is research out there about doing botox, serial casting, AFO protocols BUT the botox has to be effective, the serial casting has to have 3 series, and the AFOs have to be worn for one year. This child probably began toe-walking as a way to seek increased proprioceptive input as is VERY common in the Autistic population, though he has probably now become tight in his gastroc and/or soleus.

Unfortunately the outcome looks pretty bleak at 10 years old to break this habit. Having his family consult with an occupational therapist to create a tactile and proprioceptive based plan (sometimes called a "sensory diet") may be helpful, though it probably will not completely solve the problem.

Neil M. Scheffler, DPM, Baltimore, MD, FeetOne@aol.com

Editor’s note: This topic is now closed.

RE: Integrative Medicine (Bob Kornfeld, DPM)
From: David Secord, DPM

Editor’s note: This letter appears at: www.podiatrym.com/letters2.cfm?id=12574&start=1

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Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with potential partnership opportunity. Looking for PSR 24+ individual. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

PRACTICE FOR SALE -BOSTON SUBURBS

Established practice for sale. Practice averages 18 – 22 patients per day. Currently all surgery is referred out. Opportunity to transition patient base to full service. Priced for sale. Contact dpminboston@comcast.net

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901

ASSOCIATE POSITION -WASHINGTON - SEATTLE AREA

Two-location practice looking for long-term commitment leading to partnership. Medicare certified surgicenter each location. Must be highly motivated, ethical & have good patient skills. Competitive salary & benefits package available. Excellent opportunity for the right candidate. Send CV to fax 425-775-9078, e-mail to nwfootandankle@yahoo.com or call 425-775-1505.

ASSOCIATE POSITION - SOUTH CENTRAL PENNSYLVANIA-PM & S 36

Large, busy podiatry group looking for associate interested in future partnership. Practice facilities and technologies include: Surgical Center, Physical Therapy Department, six appointment locations, EMR, MRI and Digital X-ray. Full compensation and benefit package offered. Mail CV to Martin Foot and Ankle, 1203 S. Queen St. York, PA 17403 or email business administrator, johnreitzel@comcast.net

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multi-location practice looking for PSR-36 associate leading to partnership. PSR-36 trained podiatrist with great opportunity for reconstructive surgical practice. Practice has Medicare-approved surgery center. Must have excellent interpersonal skills. Excellent salary and incentive. Respond to: westsidefoot@yahoo.com

ASSOCIATE POSITION – MISSISSIPPI

Well established, busy, 3-doctor practice seeks PSR 12 or 24 trained podiatrist for associate position to fill vacancy of retiring member. East central location is a great area to raise a family and is a prime location for accessibility to several major cities. Competitive salary, benefits, and incentives. Partnership possible in 2 years to right individual. June - July start date. Applicant must be ethical, personable, and motivated. Please E-mail CV and letter of intent to shanegan@bellsouth.net

ASSOCIATE POSITION LEADING TO PARTNERSHIP - TAMPA BAY AREA-FLORIDA

Immediate position available in growing multi-office/multi-physician practice. Looking for a highly motivated psr24/36 trained podiatrist. Must be board qualified/board certified ABPS physician and be highly enthusiastic, motivated, with excellent patient/ social skills. Excellent benefit package including salary/bonus, health ins, paid time off, paid CME, and much more. Please e-mail CV to drdad94@aol.com or contact (727) 944-2522 for more information.

ASSOCIATE WANTED FOR SOUTH MIAMI AREA

Large group, busy, multi-office, partner potential. Motivated applicants only. Mail resumes and letters of intent to 999 N. Krome Avenue, Homestead , FL 33030. July start time OK, sooner preferable. E-mail lianadpm2@aol.com.

EXCELLENT ASSOCIATE OPPORTUNITY – SOUTHERN CALIFORNIA

Established 25 year well-rounded biomechanical and surgical practice seeking energetic, enthusiastic, personable and proficiently-trained PSR-24 or PSR-36 foot and ankle surgeon for associate with ultimate partnership opportunity in LA area. Excellent position for an individual interested in all aspects of podiatric medicine with emphasis on reconstructive foot and ankle surgery. Only 8% Medicare with No HMO. Email CV to dr4feet@sbcglobal.net

PRACTICE FOR SALE -NORTHERN CALIFORNIA

Great opportunity to own a well-established turn-key podiatry practice located in modern medical office building in East Bay; Electronic billing, good payor base, no HMO contracts; biomechanics, general podiatry with great potential for surgery. Please send CV and letter of interest to: norcalpod@hotmail.com

Attractive opportunity for enthusiastic, proficient, and personable associate. Well-established modern practice with multiple newer spacious offices, technology and equipment. Solid referral base, close to hospitals, knowledgeable certified staff. 22% MCR. Practice and surgical center partnership potential opportunity. Prefer 24-36+ PSR. Send CV: AZpodassociate@aol.com

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