The Voice of Podiatrists

Serving Over 10,800 Podiatrists Daily

March 19, 2008 #3,197 Editor-Barry Block, DPM, JD

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PA Podiatrist Gives Advice on Preparing Feet For Sandal Season

Although the March winds may have you believing otherwise, sandal season is fast approaching. If your feet need a little extra special care as they slip out of hibernation, moisturizing your feet can be a healthy start for healthier feet.

Dr. Jennifer Spector

“Using a cream or lotion containing lactic acid or urea can assist with softening and sloughing thick, dry skin,” said Dr. Jennifer Spector, a podiatrist at Accurate Foot and Diabetic Care in West Chester. “Using corn or callus remover pads are not generally recommended, since if they are not placed correctly, they can harm the healthy skin. A pumice stone can also be helpful to assist in exfoliating thick areas.

“We generally advise staying away from metal filing instruments or callus-removing razors, as they are difficult to control and can cause cuts, infections or bleeding.”

Source: Daily Local (PA) [3/17/08]

Flexibility is the Key to Toddler’s Shoes: NYCPM Dean

Buying a pair of new shoes for your toddler? Dr. Robert Eckles, a podiatrist and dean for clinical education at New York College of Podiatric Medicine in Manhattan states that sole flexibility is key. "There was in my lifetime, growing up, a tendency to want to put toddlers in these stiff-soled, laced shoes. Sometimes they were like little boots," Eckles said. "I don't think that's beneficial at all, and it may, in some instances, not be good."

Dr. Robert Eckles

A toddler really needs all the balance he can get, and a stiff-soled shoe doesn't allow the foot to bend. You should look for something that mimics the child being barefoot, Eckles said.

"There is only one requirement -- that the bottom of the child's foot is protected from things that could hurt the foot. Protect them from things that are sharp. And they should have traction. You don't want to put kids in something smooth on the bottom. You don't want to have them fall more than they already do."

Source: Goerie.com [3/16/08]

DFCon08 Called "A Massive Success" in Fight Against Amputations

The 2008 Diabetic Foot Global Conference, better known as DFCon, was declared a "massive success" by co-chairs George Andros, MD, renowned Los Angeles vascular surgeon, and David G. Armstrong, DPM and PhD, professor of surgery and director of the Dr. William M. Scholl College’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science in North Chicago, IL.

With 850 delegates from all 50 states and more than 50 nations, the annual meeting serves as a foremost gathering place for disseminating new research and practical knowledge regarding the fight against diabetes-related amputations. Andros and Armstrong also participated in a special live satellite link from the conference with about two dozen TV and radio stations across the country that reached more than one million audience members.

Advances discussed at this year's meeting included technology ranging from stem cell therapy to special thermometers that identify potentially amputation-causing wounds of the foot. DFCon also presented its 2008 Edward James Olmos Award for Advocacy in Amputation Preventions to Benjamin A. Lipsky, MD, of the University of Washington and the VA Puget Sound Acute Care System in Seattle, WA.

Query: Resistant Verruca

I have a 23 year old female patient who is being treated for a plantar verruca.The verruca has been resistant to laser and other topical treatments. It continues to increase in size since she was originally seen in November. At her last visit, she stated that she was undergoing the Herpevac herpes vaccination, which she has had two of three injections. The first injection was in July and two weeks later she noticed the wart on the bottom of her foot. Has anyone had any similar circumstances or have any insight? The correlation is quite interesting.

Jodi Schoenhaus, DPM, Boca Raton, FL

Query: Needle Aspirate Biopsy-Steroid Injection

I recently did a needle aspiration biopsy of a suspected ganglion. I then injected 1 cc. of steroid. I coded the procedure, CPT 10021 (fine needle aspiration; without imaging guidance) with ICD-9 238.1 (connective and other soft tissue). Is it also proper then to code the steroid injection as CPT 20550 (injection, tendon sheath, ligament, plantar fascia)?

Charles Perry, DPM, Cambridge, OH

Response: You "aspirated and injected" a ganglion. This is coded as CPT 20612 (aspiration and/or injection of ganglion cyst(s) any location). Submitting any obtained material aspirated from the ganglion would be incidental to the CPT 20612 coding.

Be sure to listed and bill for the steroid injected.

Tony Poggio, DPM, Alameda, CA

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RE: Painful Nails in Patient With Raynaud's Disease
From: Multiple Respondents

I'm curious about this case. The patient lives in the area of Redondo Beach, which is in Southern California. Its fairly warm all year long that part of the country. We treat many patients with Raynaud’s Phenomenon but we are in the New York area where we get ice cold winters. We find that our Raynaud's patients come in with symptoms starting in the late fall and their symptoms abate roughly in April and sometimes earlier . Our April weather is probably still colder than the weather in Southern California in January and February. With this is mind, could there be something else going on with the patient other than Raynaud's phenomenon? There are many other diseases which can cause painful cyanosis of the toes. What type of testing was done that ultimately lead to the diagnosis? Secondly if this patient does in indeed have classical Raynaud's phenomenon, is she being treated with medications such as long acting versions of Nifedipine-type calcium channel blockers combined with shoe warming devices? These medications so long as there are no cardiac contraindications can improve her quality of life and make your work with her easier as well.

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

I am in agreement with Dr. Markinson's analysis.. You need to rule out all other medical causes, e.g., vasculitis, vasospasm. Is it Raynaud’s disease or Raynaud’s phenomenon? There is a big difference! When are we going to become more diagnosticians rather than technicians.

Issues of nail care coverage need to be addressed with you local carrier, and patient might need to pay out-of-pocket.

Simon Young, DPM, NY, NY, simonyoung@juno.com

I agree with Dr. Markinson, and respectfully disagree with Dr. Poggio. It is my understanding that Dr. Poggio insists there are no "other reasons" for continued evaluation of this condition by the podiatrist, after initial examination.

A brief review of (some) differential aspects of this disorder or disease cry out for further evaluation, based upon history, physical diagnosis and laboratory evaluation. One can also make a referral to a vascular surgeon to continue to evaluate this condition:

Connective tissue disorders: scleroderma, systemic lupus erythematosus,
rheumatoid arthritis, Sjögren's syndrome, dermatomyositis, polymyositis
eating disorders, anorexia nervosa, obstructive disorders, atherosclerosis
Buerger's disease, subclavian aneurysms, thoracic outlet syndrome.
Drugs: Beta-blockers, cytotoxic drugs - particularly chemotherapeutics and Most, especially bleomycin, cyclosporine, ergotamine, sulfasalazine
Occupation: jobs involving vibration, particularly drilling, exposure to vinyl chloride, mercury exposure to the cold (e.g. by working packing frozen food)
Others: hypothyroidism, cryoglobulinemia, malignancy, reflex sympathetic dystrophy

It is possible for the podiatric physician to take numerous appointments to review the patient and make an attempt to get a differential diagnosis established. After all, this is a condition, while it may have systemic roots, clearly presents itself in our anatomic definition of legal practice in every U.S. state.

The diagnosis of Raynaud's disease or phenomenon places this into E and M context, not routine foot care. If the podiatric physician makes an effort to evaluate the patient in detail, that is their choice. More than one appointment will be necessary to accomplish this in most cases.

Michael M. Rosenblatt, DPM, San Jose, CA, ROSEY1@prodigy.net

RE: Texas Appeals Court Overturns Scope of Practice Definition
From: Patrick J. Nunan, DPM, Bryan C. Markinson, DPM

I find it quite disturbing to read the decision handed down by the appeals court in regards to the ankle not being within the scope of practice of podiatric physicians in the state of Texas. More alarming is the comments and background of the president of the Texas Medical association (TMA). He is a pathologist at the University of Texas, San Antonio who also does work for a large national pathology chain that many of us use for tissue diagnosis. Not surprising to find out was that his father was an orthopaedic surgeon and his son hopes to become one. Despite all the advances we have made in our training and education, we are still and will continue to be discriminated against by a large segment of the medical community. To me this speaks volumes for the importance of contributions to our national and state political action committees. The fight continues and we cannot afford to bury our heads in the sand any longer. While we have accomplished much as a profession, we cannot let our guard down.

Patrick J. Nunan, DPM, West Chester, OH, PJNDPMRUN@aol.com

This reversal on appeal is a stunning blow. It does appear however, that the decision centered more on unlikely aspects of the beaten down statute rather than the medical realities. For example, the appeals court concluded that as written and initially passed, a DPM could not be stopped from treating a patient with a sarcoma in the calf muscle. This is what lost the battle, not the ability to close a posterior tibial tendon defect that happened to extend a few millimeters above the ankle.

Don't you think that if the appeals judges were shown a photo of a venous ulcer that was half on the foot and half on the ankle and they needed to decide why the top half was out of scope while the bottom half was in scope would have better illustrated our dilemma. We need to make it clear in some way other than anatomical boundaries that the expanded scope we seek is to eliminate these gray areas, and not to tread where we are not trained.

Of course, the MD/DO degrees allow unfettered anatomical and procedural scopes, relying totally on self-policing to protect the public from these practitioners from doing things that they are not trained to do, but licensed to do. The DPM degree is given no such slack. This absurdity must be better articulated.

Bryan C. Markinson, DPM, New York, NY, bryan.markinson@mountsinai.org

RE: Alleged Failure to Order Bone Density Test
From: William A Sachs, DPM

I was the defendant podiatrist in this case. Although, at my attorney's suggestion, I consented to a right to settle, my attorney settled without ever informing me he was doing so.When I received a letter from the National Data Bank informing me of the settlement I called the attorney to question him as to why he did not discuss this with me first, since the last correspondence I had received was to tell me we would be going to trial in a month. He had the nerve to tell me that he did me a favor since my coverage was limited to $300,000 as a result of my insurance company declaring bankruptcy.

At the time, I was insured by PHICO, which had been endorsed by our society. Prior to settling, my attorney was quite confident we had a very winable case! Truth be told, he was probably satisfied he had sucked all the fees he could out of the case, and it was time for him to move on!

Oh, and by the way....the plaintiff did not have an "ankle fracture" as mentioned in the Jury Verdict Reporter. There was some question that she may have had a stress fracture of her tibia 2 years after her metatarsal stress fracture. And as far as her weight loss, during my deposition I was asked if I noticed if she had lost weight during the approximate 8 month period that I hadn't seen her? And it was in November when we are bundled up! The bottom line is that nothing is a "slam dunk" and we need to all be careful!

William A Sachs, DPM, Toms River, NJ, wmasachs@gmail.com

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