The Voice of Podiatrists

Serving Over 14,000 Podiatrists Daily

February 09, 2013 #4,687 Publisher-Barry Block, DPM, JD

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CA Podiatrist Discusses Treatment of Plantar Tears

L.A. Lakers' Pau Gasol will be out indefinitely after suffering a tear of the plantar fascia of his right foot in Tuesday's win in Brooklyn. Gasol had an MRI Wednesday, but will fly today to Los Angeles for more evaluation from Lakers' team doctor Steve Lombardo, and foot specialist Dr. Kenneth Jung.

Dr. Robert Khorramian

"If it's a one-third tear, within four to six weeks, he should be okay," said Dr. Robert Khorramian, a Santa Monica foot and ankle specialist. "If it's a two-third tear, it would go much higher, possibly eight to 10 weeks. When there's over a two-third or a complete tear, we advise surgery. That takes 12 to 14 weeks."

Source: Mark Medina, The Los Angeles Daily News [2/6/13]

Podiatry Student Featured in Temple University Video Profile

Michael L. Sganga, a fourth year student at the Temple University School of Podiatric Medicine, was recently featured in an online video produced by Temple University.

Michael L. Sganga

Notably, Sganga founded the first forensic podiatry club at a college of podiatric medicine. "My transformative experience at Temple was my first week in clinic — getting out of the classroom and seeing patients for the first time. Learning about podiatry in the classroom is one thing. It's another thing entirely when you're sent to a room with a patient and chart in your hand, and you need to figure out what's wrong by asking the patient questions and listening to his or her answers."

Source: Megan Chiplock, Student Success [2/1/13]

Lawmakers Offer Dueling Approaches on Fixing Doc Pay

Both a bill introduced Wednesday by Rep. Allyson Schwartz (D-PA) and a bill expected from Ways and Means Health subcommittee Chairman Kevin Brady (R-TX) would replace the sustainable growth-rate formula with temporary increases while replacement methodologies were devised. But the bills differ on important points, including whether federal officials or physician groups would take the lead in developing new payment systems and the degree to which fee-for-service payments would be eliminated.

Schwartz's bill would mostly unravel the fee-for-service system by requiring physicians to adopt one of several replacement models that the CMS would test and approve over five years. Physicians who did not do so would face successive payment cuts, although a small number of physicians could remain in a modified fee-for-service system if they met certain quality benchmarks or were near retirement. The Republican alternative, according to a Ways and Means Committee memo, would continue wide-scale use of a modified fee-for-service system while offering extra payments for physicians who undertook efficiency improvements.

Source: Rich Daly, Modern Healthcare [2/6/13]

Query: ZocDocs

What experiences have any of the readers of PM News had with ZocDocs, the online patient scheduling service?

David C Greenberg, DPM, Portland, OR

Query: New Patient?

If a patient has not been seen for 5 years, can we bill for a new patient E/M service?

Barbara Mitchell Office Manager, Office of R. Bruce Franz, DPM, Arcata, CA

Response: The official definition of a "new patient" is one who has not been seen by that physician or any physician of the same specialty within the same group, within the past 3 years.

Some representative examples: You are a podiatrist in a multispecialty clinic. You have not seen the patient in over three years, but the patient HAS been seen by an orthopedist in your group within three years. This is a NEW patient for you.

Same scenario, but the patient has seen another of your podiatric colleagues in the same group in which you practice within the past three years. This is an ESTABLISHED patient for you.

Rick Horsman, DPM, Olympia, WA

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RE: Etiology of Hallux Varus (Jordan Sheff, DPM)
From: Dimitri Yagdjis, CPO

Commonly, I have seen that the dominant Achilles overpowers the weaker PF which normally results in lateral displacement of the calcaneus and pronation. Some patients, without realizing, over-compensate for this dysfunction by forcing themselves into supination. This may bring them relief for plantar fascia or genu varum (medial compartment knee) pain caused by the pronation. Note that many patients don’t even realize they have pain because the accommodation is quick and automatic. The supination relieves the pain, similar to the use of a medial sole wedge.

I have observed that hallux varus is often a result of supination in the same way that hallux valgus is often caused by a pronated gait. Every time a pronator rolls through terminal stance, the constant and repeated laterally directed force on the hallux slowly causes the bunion deformity. Constant and repeated medial directed force is exerted on the forefoot during supination, mechanically causing the deviation.

The solution I have used has two parts. First, I find that I must solve the plantar fasciitis issue by supporting the arch at the sustentaculum tali along the posterior tibial tendon - or  the pain will cause the patient to continue supinating the foot. Second, I support the lateral arches of the foot at the inferior-lateral regions of the peroneus brevis and shaft of the 5th metatarsal. Once these two parts are accomplished, I might add a 2-3 degree lateral wedge for stubborn supinators.

Dimitri Yagdjis, CPO, Van Nuys, CA, dimitri@amprosthetics.com

RE: Alternative to Onycol (Michael Forman, DPM)
From: Stephen Musser, DPM, Scott M. Aronson, DPM

As for topical treatment of mycotic toe nails, I have had the most success with Formula 3.
 
Stephen Musser, DPM, Cleveland, OH, ly2drmusser@gmail.com

I have been using Formula 3 Antifungal Solution (Tetra Corporation) for several years. Patients have been extremely satisfied with the results for interdigital tinea pedis as well as onychomycosis (off-label). I have them apply the oil-based solution to the base of the nail twice daily. I continue with debridement until maximum results have been achieved. It is a great product to offer (sell) in your office as it is backed by an unconditional, patient-direct, money back guarantee...no questions asked! 

Scott M. Aronson, DPM, Stoughton, MA, s_aronson@yahoo.com

RE: Source for Custom Dress Shoes (Charles Morelli, DPM)
From: Robert S. Schwartz, CPed.
 
Eneslow makes stylish custom dress shoes for hard-to-fit feet in our on-site lab at 470 Park Avenue South, NYC location. Our custom shoe-makers have over 100 years combined experience. Importantly, we can customize any shoe that your patient already owns to better fit their feet (shoe makeover).

Robert S. Schwartz, CPed, NY, NY, rss@eneslow.com

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, afootdoc@hotmail.com

RE: Diabetic Therapeutic Shoe Bill (Michael Hames, DPM)
From: Paul Kesselman, DPM)

With all the DME fraud and abuse, who can blame the Feds for kicking back with more audits? However, they have kicked the ball way too far to the other side of the court.

It appears to many of my colleagues (and I would agree) that there are far too many ill-trained auditors who seem to be ignoring the materials put in front of them. One can't blame those providers who don't dot every "i" or crossing every "t" from being frustrated.

This problem is not unique to podiatry and it has been...

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

RE: Diabetic Therapeutic Shoe Bill (Josh White, DPM, CPed)
From: Dale Feinberg, DPM, CPed

While at the recent Professional Footware Association meeting in Little Rock, Arkansas, I had the opportunity to discuss my difficulties of Medicare audits with Dr. White. I reviewed  his documentation. Just getting the primary care doctor to agree with your extensive note doesn't cut it in Fargo, North Dakota. 

I am not disagreeing that other podiatrists in other regions have less difficulty with the program, but unfortunately these are my experiences as a full-time practitioner who is in the trenches everyday, and not a middleman who is not fiscally responsible for Medicare audits.

Dale Feinberg, DPM, CPed Yuma, AZ, hd5bl@aol.com

RE: CA Podiatrist Discusses Treatment of Plantar Tears
From: Neil H Hecht, DPM

The Daily News sports section, dated Thursday, Feb 7, 2013, in Los Angeles was reporting Laker’s player Pau Gasol’s plantar fascial injury. In the article, a podiatrist, Robert Khorramian, DPM, is quoted as follows - “If it’s a one-third tear, within four to six weeks he (Gasol) should be okay. If it’s a two-third tear, it would go much higher, possible eight to ten weeks. When there’s over a two-third or a complete tear, we advise surgery. That takes 12 to 14 weeks.”
 
I have queried several of my associates and none of us agree that any surgical care for plantar fascial tears would be appropriate. Any comments from the readership? Is there any literature that validates such a surgical intervention? Is the orthopedic community engaging in surgical repair for this injury?
 
Neil H Hecht, DPM, Tarzana, CA, drhecht@drneilhecht.com

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