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February 17, 2007 #2,812 Editor-Barry Block, DPM, JD

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DC Podiatrist Recommends Crocs to His Patients

Some doctors are recommending Crocs to patients with foot problems. "These shoes are especially light," says Harold Glickman, DPM, former president of the American Podiatric Medical Association (APMA). "They have huge room in the toe that affords the front part of the foot lots of room, especially for people with bone deformities like bunions and hammer toe. With the Rx Crocs, they're lined with antibacterial material that will prevent fungal and bacterial infections."

Dr. Harold Glickman

For people with diabetes, Crocs offer added value in the protection they provide. Because people with diabetes have reduced circulation in their feet, Glickman says, they're at higher risk for open sores and wound infection. The spare room and antibacterial properties of Crocs help combat these problems.

"I do not have stock in the company or work for the company, but I recommend them to patients all the time, and I wear them all the time," Glickman tells WebMD. "I wear them when I'm operating for three or four hours at a time and I get the sense I'm standing on water -- no leg pain, no back pain, and no arch pain."

Source: Heather Hatfield, WebMD [2/15/07]

TX Podiatrist Publishes Medical Mystery Novel

In the morning hours, he teaches health sciences at Kempner High School. In the afternoons, he is a podiatrist and performs surgery. Now, he is the author of a medical thriller. To boot his multifaceted personality, Dr. Jeff Ricken of Sugar Land, is a sailor and pilot, not to speak of his skill in playing the piano and guitar.

Dr. Jeffrey Ricken

"My first novel The Circle's Corner is based on my years of practicing medicine and surgery, five years living in Austria where I studied human anatomy in a graduate school and from sailing around the world for five years," Ricken said.

The Circle's Corner

The plot of The Circle's Corner includes disparate elements such as evil doctors who conspire to threaten Galveston; a doctor assaults a young female patient; and a fetus of unknown parentage is conceived 60 years ago and whose identity might have political consequences to the stability in America. "It's filled with dozens of plot twists and symbols and cipher codes to challenge the reader," Ricken said.

Source: Seshadri Kumar, Houston Chronicle, [2/15/07]

TUSPM Professor To Present on May-Hagglin's Disorder at ACFAS Meeting

Dr. Jason Miller

Jason Miller, DPM, assistant professor in TUSPM’s department of surgery, will be presenting a poster abstract/paper entitled, “May-Hegglin’s Disorder and other platelet dysfunctions as a consideration in compartment syndrome” along with Peter Moyer, DPM at the national ACFAS scientific meeting, March 14-18 in Orlando, FL

Query: Formula 3 Topical Antifungal

Last week a drug representative stopped by my office to discuss Formula 3, a new topical antifungal. The company claims a direct money-back guarantee to the patient if it does not work. Has anyone used this product who would care to comment. They don't sample.

Philbert Kuo, DPM, Chesapeake, VA

Query: CPT 90772 Plus CPT 20550 Coding

A colleague of mine said we should include the code, CPT 90772 (therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular), when administering heel, neuroma injections along with CPT 20550 (injection, tendon sheath, ligament, plantar fascia) for private insurance companies. Is this allowable?

Alan Pittle, DPM, El Paso, TX

Response: Your colleague is incorrect. First, the correct use of CPT 90772 is when an injection is administered for systemic therapy. CPT 20550, on the other hand, is billed when an injection is administered into/around a symptomatic tendon sheath, ligament, or plantar fascia.

Second, it is never appropriate to double bill an insurance company by submitting two codes for the same procedure. The National Correct Coding Initiative (NCCI) pairs CPT 90772 and CPT 20550 together with a "1" in the modifier column indicating that the two codes can only be used together on the same date of service if they are in distinct locations or for separate problems. While the NCCI is only mandatory with Medicare, many private insurers use it as well.

Incidentally, you indicated in your post that you would use CPT 20550 to code for a neuroma injection. While some Medicare and private carriers may insist that you use this code for a therapeutic neuroma injection, the APMA Coding Committee has gone on record that the correct code for a therapeutic neuroma injection is CPT 64450 (peripheral nerve block, therapeutic). Unless a private insurer has directed you to use CPT 20550, I suggest that you use CPT 64450 when injecting a neuroma with cortisone.

Mark Schilansky, Catskill, NY

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RE: Compression Neuropathy while Skiing (Alex Dellinger, DPM)
From: Robert Scott Steinberg, DPM, Peta Minerof, DPM

The two most common causes are buckling the boot to tight - mostly because the boots are too big, and the skier's stance. Most skier lean back. This presses the calf against the back of the boot. The "leverage" forces the foot forward and the instep up against the tongue.

If you have identified the exact location of the "pinch", then you should be able to direct any competent boot fitter to that location. He should be able to do what in the boot fitting industry used to called a "Coke Bottle Punch".

A few other things.... Are the skier's custom insoles stabilizing the foot? Is the custom insole too thick? If he truly has a high arch rigid foot type, make sure the boot fitters have not added any heel lift under the custom insole OR under the liner.

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

Even when the in-store fit appears very good, outdoor conditions can stiffen the ski boot. Some shops have suggested wearing the boots at home for up to an hour to determine if there are any subtle fit problems. I have a few simple suggestions:

Socks: Many skiers wear multiple pairs of socks in an attempt to keep the feet warm. Bad idea. This backfires by clamping down on the blood vessels, worsening the problem and causing lots of discomfort. Try one pair of well-designed ski socks with a polypropylene inner layer or sock liner to wick away sweat. It's usually the sweat that cools, making to foot feel cold. I might also try using a self-adhesive foam cut-out on the foot proximal to the area of discomfort or bony prominence and see if that helps.

Boots: Loosen, rather than tighten down the boots. Many skiers will close down the boots very tightly, again compromising circulation and causing neuropathy. Find a good ski boot fitter and make sure the ski shop adjusts the boots to provide as personalized a fit as possible. *Boot latches can often be adjusted to provide more or less closure at the latch, giving the skier a more appropriate range of adjustments while on the slopes. A good ski shop should also be willing to work with the customer until the boots are functional.

* The boot fitter can "blow-out" the hard plastic shell in the area of impingement. This allows the overall shell to remain the same, but relives the pressure in the area over bony prominence. Adding a foam cut-out pad to the inner surface of the shell should further cushion the area should also help. Above all, consult an experienced boot fitter about this. They have many sophisticated tricks up their sleeves.

Peta Minerof, DPM, Chicago, IL, Pminerof@aol.com

RE: Post-op Allergic Reaction? (David Gutierrez, DPM)
From: Barry Mullen, DPM

True allergic reactions to Vicryl suture are rather rare and typically would not cause the entire digit to inflame. More commonly, sterile suture abscesses form when the suture material is placed too close to the skin and the body cannot fully hydrolyze it. They look like small zits within the incision line, are rather tender to direct palpation and irritated by shoes, but are easily eliminated. Depending upon your normal skin closure technique and post-op wound care, there are 2 common topical allergens utilized by some podiatric surgeons which are notorious contact dermatitis initiators 1. Neosporin 2.Tincture of Benzoin. Lastly, double-check your patient's medical history and ensure they don't have a latex allergy (fairly common) that went undetected pre-op.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

RE: Refractory Hyperhydrosis
From: Sheldon Laps, DPM

I have a solution for you regarding hyperhydrosis. Have your local pharmacy compound the following prescription: Formalin in rosewater, 15mn qsad 30. The rosewater is added to "sweeten the pungent aroma given off by the formalin, which is a powerful drying agent. Have the patient apply this solution to the soles of the feet at bedtime.

Sheldon Laps, DPM, Washington, DC, slapsdpm@comcast.net

Editor’s note: This topic is now closed

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