The Voice of Podiatrists

Serving Over 10,800 Podiatrists Daily

March 26, 2008 #3,203 Editor-Barry Block, DPM, JD

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Fashionable Spring Shoes Can Spell Trouble For Feet: NC Podiatrist

Spring is here. Heavy socks are being stashed away in drawers. Capri pants are making their way to the front of the closet, and high-heel, strappy sandals are one step closer to coming out of hibernation. Before slipping into your fabulous fashion statement, you may want to heed the warning of an area podiatrist: Your tootsies could be in for a torturous ride when strutting around in 4-inch spiked heels or platform wedges. And there could be a price to pay.

Dr. Matthew Thompson

“Wearing high-heel open sandals is asking for trouble,” said Matthew Thompson, a podiatrist at Cape Fear Podiatry Association in Lumberton. “You’re putting a whole lot of extra pressure on the top of your foot and the toes.” Problems can include bunions, hammertoes, heel spurs, corns, and calluses.

Thompson said the most common ailment he sees is corns between the fourth and fifth toes. The condition is caused when a person squeezes her foot into a shoe that isn’t wide enough. Although sandals are usually open, it doesn’t stop the problem. “The mechanics are all the same,” Thompson said. “You’re still putting a whole lot of extra pressure on the top of your foot and the toes.”

Source: Hilary Kraus, Fayetteville Observer [3/24/08]

Scholl's Wu Named to JAPMA Editorial Advisory Board

Stephanie C. Wu, DPM, MSc, Assistant Professor of Surgery at Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science was named to the Editorial Advisory Board of the Journal of the American Podiatric Medical Association (JAPMA). The journal, founded in 1907, is the oldest and most frequently-cited peer-reviewed journal in the profession of foot and ankle medicine.

Dr. Stephanie C. Wu

"I am tremendously honored by this appointment,” said Wu, who is also Director of Education at Scholl's Center for Lower Extremity Ambulatory Research (CLEAR). "The ability to work closely with the top lower extremity research journal is a distinctive professional privilege." Dr. Warren S. Joseph, JAPMA's Editor-in-Chief, noted "Dr. Wu represents a new generation of highly-trained, academic podiatric physicians. She has already made great contributions to the Journal as both an author and an exemplary reviewer. Her election to the Board was by unanimous decision at our recent editorial advisory meeting."

Dr. Wu, in addition to her clinical and research responsibilities, manages visits to CLEAR by visiting professors, fellows and other clinicians each year from dozens of nations.

NJ to Consider Universal Health Coverage

New Jersey’s legislature will take up the issue of universal health coverage after state Sen. Joseph F. Vitale (D) introduced a package of bills. The legislative package is aimed at covering all New Jersey residents by the year 2011. In its first phase, uninsured children of families with incomes of less than 350% of the federal poverty level would be automatically enrolled in Medicaid or one of the state’s FamilyCare income-tiered programs when they go to a provider.

Vitale said that focus would help meet federal enrollment guidelines for the State Children’s Health Insurance Program (SCHIP), and would preserve additional matching federal dollars for the state. The second phase would be introduced in 2009 and would create a self-funded, state-sponsored health plan for all individuals,

Source: Health Plan Week [3/24/08]

Query: Is Penlac the Standard of Care?

I have a patient that came to me complaining of thick painful toenails. The patient is unable to take an oral antifungal agent. Mycology specimen of nail and subungual debris confirmed the clinical diagnosis. I explained to the patient there is a topical antifungal agent Penlac, which is FDA-approved for this condition. The patient tried filling her RX and I was sent a copy of the determination which reads "Given a poor clinical clearance of less than 10% for Penlac in the setting of onychomycosis, the standard of care in this setting does not include the use of a topical anti-fungal agent."

My question is how or why was this medication FDA-approved? If it is the only FDA-approved topical medication for this condition, isn’t it the standard of care?

Jeffrey Kass, DPM, Forest Hills, NY

Query: ICD-9 Coding for Total Contact Cast

What are allowable ICD-9 codes that can be linked to application of total contact casts (CPT 29445)?

Michael Fein, DPM, Bethel, CT

Response: Obviously, any specific ICD-9 code requirement will be payer-dependent. While many payers may not have specific ICD-9 linked codes for total contact cast use, I would think since a total contact cast application is associated with ulcer treatment; an ulcer diagnosis code would qualify the application reimbursement. A quick look at First Coast Service Options' website reveals no policies or utilization guidelines for total contact casting.

Harry Goldsmith, DPM. Cerritos, CA

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RE: Chronic Severe Pain Left Hallux (Bruce Krell, DPM)
From: Multiple Respondents

It certainly looks like his patient has a chronic neuritis of the dorsolateral proper digital branch to the hallux, possibly even involving the plantar digital branch as well. Following excision of a soft-tissue mass, scarring to the hallux may have increased entrapment of this nerve, thereby increasing this patient's pain and symptoms.

Since local nerve block is effective but temporary, chemical neurolysis using alcohol sclerosing injections could prove effective as well as neurectomy. The injection therapy may be very painful, and neurectomy may produce a stump neuroma. I would like to add cryosurgery to the possible treatment options. Cryosurgery is a minimally invasive, highly effective treatment for single branch neuritis, and rarely, if ever, creates a stump neuroma. I have used this treatment modality for the past three years, and have had good success with minimal complications.

Todd Lamster, DPM, Phoenix, AZ, tlamster@gmail.com

A nerve injury to the toe is certainly possible. EMG will often be neg. with very small diameter nerves. The dorsal lateral location you describe may indicate more of a deep peroneal injury. The nerve can easily be injured by a tight shoe, as it crosses under the EHB tendon. Try giving a small nerve block (1\2 cc of lido) to the deep peroneal and see if that relieves your patient’s pain. If so, then you should do well treating at this level. Alcohol may work or you may have to do an open decompression. If it was only a digital branch that was injured, I am thinking it would have repaired itself by now.

Gregory Mowen, DPM, Ventnor, NJ, gregmowen@comcast.net

When evaluating a patient with neuropathic pain that is not responding to traditional evaluation and treatment, we often need to think out-of-the-box. Any impingement anywhere up to and including the area of the lower spinal column can cause peripheral neuropathatic pain. The symptoms might appear to the patient to be emanating from one part of her lower extremity but the actual pathology might be from pressure or an impingement on a peripheral nerve higher up.

I have had several cases with almost the same history that Dr. Krell’s patient presented and all of these patients had complete resolution of their symptoms with the use of functional foot orthotics. One of these patients was sent to me by a neurologist who put his hands up in air after all neurologic tests failed to yield a definitive point of nerve impingement. The patient’s symptoms completely resolved after he started using orthotics. What made these patients' symptoms abate was not solely the treatment of abnormal pronation but by introducing a change in the biomechanics of the lower extremity with functional orthoses we were able to remove a minor nerve impingement which resulted in the patients feeling better.

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

RE: ACFAS / APMA Membership Vote
From: Allen Mark Jacobs, DPM

Dr. Markinson is correct that many can no longer afford both APMA and ACFAS dues. I would like to reiterate my position that there should be a divestiture of APMA membership from the requirement of mandatory simultaneous membership to state and local societies, thus reducing cost for APMA membership.

We need the APMA. We need ACFAS.

Allen Mark Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net

RE: Outside Payroll Services (Bob Levoy)
From: Pete Harvey, DPM

One of the responses to this topic mentioned Paycycle. Check their website. They are excellent. They also coordinate with your local CPA for tax preparation. One other very important site is www.eftps.gov/eftps/ Pay your estimated taxes direct to Uncle Sam weekly and not quarterly. Stay ahead and get a refund instead of a tax shock.

Pete Harvey, DPM, Wichita Falls TX, pmh@wffeet.com

RE: Value of APMA Membership (Bryan C. Markinson, DPM)
From: Bob Kornfeld, DPM

If what Dr. Markinson says is true, that "there are probably more practitioners embarrassed to say they can't afford" the dues payments, then there is a lot more work to do than simply focusing on scope of practice legislation. I am very outspoken in regards to the whole "managed care" mess that the medical profession seems to have gotten itself into. How illogical is it for anyone to spend 4 years in podiatry school, do a residency, enter into practice with a huge knowledge and skill base in podiatric medicine and surgery, only to find that they can't make ends meet. This makes the scope of practice question irrelevant in my mind.

I do not participate with any insurance companies at all. I have a low-volume, high-income practice. When I speak to other podiatrists and urge them to drop out of insurance plans, I am always told the same thing, "my patients will never pay for my services, they'll just go to another practitioner". There are TWO problems with this mentality. The first one is that if you believe that, then it will manifest that way. Patients will pick up very quickly on your own reticence to charge for your services. It is critically important to re-condition the patient population into placing value on your services.

The second problem is, what is going on with podiatrists that they feel their services are not worth paying for? Patients are not the only ones who need to be re-conditioned. It is the podiatrists themselves that need to be as well. As far as patients "going around the corner" where the care is cheaper, yes they will go. So our challenge now is unifying the profession somehow, taking a stand against managed care as a "whole" and putting medicine back where it belongs...in the hands of the doctors. I will be happy to assist in any way I can.

Bob Kornfeld, DPM, Lake Success, NY, Holfoot153@aol.com

ASSOCIATE POSITION - CHANDLER/GILBERT/PHOENIX, AZ

Multi-location office and soon to start a wound care office in a local hospital. Seeking a well-trained graduate of a PSR 24+/36 Residency. This is a practice with a nice mix of 35% surgery/trauma, 20% diabetic/wounds, 25% biomechanics, 20% pediatric. ER Call for 2 hospitals. Opportunity for partnership at 2 surgery centers. Very modern office with EMR, U/S, Digital X-Ray, Vascular Testing /Nerve Testing Machines and our own ESWT. Excellent referral base, and a well-trained certified staff. Board eligible/certified a plus. Competitive salary, bonus structure, benefits. Please e-mail CV and references to main@footanklespecialtycenters.com

ASSOCIATE POSITION – CONNECTICUT

Connecticut Surgical Group, one of the largest multi-specialty surgical group practices in New England, is seeking a Podiatrist to add to our three-physician Podiatry division based in Hartford. Provide all aspects of Podiatric care with a focus on wound and surgical care to a well-established patient base. PSR-36 training and board certification or eligibility and excellent surgical and wound care skills required. We offer competitive salary and productivity bonus, partnership opportunities, excellent benefits, and reasonable overhead. Apply online at https://home.eease.com/recruit/?id=21426 or via our website or fax your CV to 860-524-2653. No phone calls. EOE

ASSOCIATE POSITION NYC AND STATEN ISLAND

Associate needed for NYC and Staten Island. Spanish speaking a plus. Must have 2 years training . Growing practice with possibility of partnership. Please Send CV to Staff@nynjfoot.com

ASSOCIATE POSITION - NEW YORK CITY

Excellent opportunity for foot/ankle surgeon, Manhattan and Brooklyn Associate position leading to possible partnership. Requirements: Two years enrollment in a surgical residency program Qualities of self-motivation and impeccable skills in forefoot and rear-foot surgery. Package Includes: Malpractice insurance, Health Insurance plus salary, Incentives. Terms negotiable Email CV to Manfootcare@aol.com 212-349-7676

PART TIME PRACTICE W/ PROPERTY FOR SALE, BLOOMFIELD, NJ

Very busy 3 days/week. All modern equipment including digital x-ray and recently remodeled office suite. Office over 1300sf with 3 treatment rooms, large consultation room and second private office suite with full bathroom. Located in a professional building with plenty of parking on a main road. Bus stop in front. 2 blocks off Garden State Parkway. Please contact doccapo@yahoo.com

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