The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

April 03, 2009 #3,510 Publisher-Barry Block, DPM, JD

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Degeneration a Factor in Plantar Fasciitis: CA Podiatrist

Orthopedic foot surgeons and podiatrists say plantar fasciitis can be difficult to treat and unpredictable to cure, not to mention nearly impossible to prevent. The underlying cause remains a matter of debate among specialists.

Dr. Kevin Kirby

Researchers posit that repetitive trauma to the fascia can lead to irritation that, in time, leads to degeneration of the tissue itself. Podiatrists such as Kevin Kirby say degeneration is the biggest obstacle to overcoming the condition.

"When you're 10 years old, the fascia are like rubber bands - they stretch and go back," Kirby says. "With an older person, it's like paper. You pull on them and they rip. Maybe not that dramatic, but that's what happens. When (fascia) are put under a load and stretched repeatedly for years and years, they are more likely to get these little tears."

Source: Sam McManis, Sacramento Bee [3/22/09]

APMA Survey Shows Nearly 40 Percent of Americans Reel From Heel Pain

While foot problems such as bunions, corns and dry, cracked skin affect many Americans on a daily basis, one particular ailment -- heel pain -- stands out among foot disorders, according to a new survey by the American Podiatric Medical Association (APMA). The 2009 APMA survey, which polled close to 420 Americans aged 18 and older, found that 39 percent of adults have experienced heel pain more than any other foot ailment within the last 12 months.

Dr. Ronald Jensen

Additionally, nearly 60 percent of respondents believed they suffered heel pain while wearing ill-fitting footwear. However, 64 percent of respondents said they had not yet visited a medical professional -- such as a podiatrist -- to diagnose and treat their heel pain.

"Heel pain is a detrimental foot ailment that affects millions of Americans every day, and foot pain of any kind is not normal," said Ronald D. Jensen, DPM, president of the APMA. "If detected early, most types of heel pain -- including the most common, plantar fasciitis -- can be treated with non-invasive treatment options. However, the longer one waits to have their heel pain evaluated, the more difficult it is to successfully treat."

Source: USNewswire [4/2/09]

OK Podiatrist Promotes Foot Health Month to Cherokee Nation

April is Healthy Foot Awareness Month, and the Cherokee Nation has a proactive comprehensive approach to foot care. Dr. Juliet Burk, a podiatrist at Three Rivers Health Center in Muskogee, OK said all diabetics should get annual foot screenings to help check for risk factors that lead to amputations. 

Dr. Juliet Burk examines a patient's foot. (Photo courtesy of CN Communications)

“Our pride is that for Healthy Foot Month, we only need to broaden our invitation to all Cherokee people to come by and visit one of our foot doctors if you have any foot concerns,” said Burk. “A diagnosis that is not backed up by medical expertise may never help you answer the question, “Why me?” Your podiatrist can help you get better and reduce your risk of relapse.”

Since Native Americans have a higher risk of developing diabetes than other races, it is necessary they stay educated on health topics that go along with having diabetes. “Cherokee people – even the children – should be proactive in considering long-term risks,” Burk said. “For instance, a beautiful Cherokee teen-aged girl or young woman might want to reconsider regularly wearing high-heeled, narrow-toed shoes that lead to bunions and hammertoes (two common foot deformities).” 

Source: Jami Custer, Cherokee Phoenix [3/31/09]

Conflicting CMS Guidance About Physician Signatures on Orders Creates a Quandary

Despite CMS's recent clarification that physicians don't have to sign orders for outpatient diagnostic testing, there's doubt about the real-world application of this position for many hospital-based providers. Not only has CMS taken a somewhat conflicting position in another forum, but the Joint Commission appears to require physician signatures on all orders, sources say. And hospitals potentially could have problems with program-integrity auditors if their orders lack physician signatures.

In the now-famous Transmittal 248 (Change Request 5971), which barred physician signature stamps, CMS conveyed the necessity of having physician signatures in written or electronic form. "Medicare requires a legible identifier for services provided/ordered," says the transmittal, issued in March 2008. But Transmittal 94, implemented on Sept. 30, 2008, said that "while a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed."

Source: Nina Youngstrom, Report on Medicare Compliance [4/2/09]

Query: Pain Post-op Arthrex Tightrope

I recently tried my first Arthrex tightrope for a bunion deformity. The patient is now 11 weeks post-op and complains of pain to the second metatarsal for the last 5 weeks after coming out of a BK walker, as if she had a stress fracture of both feet. There is good correction noted for the bunions. There is swelling to the second met area, but no signs of a stress fracture on x-ray. The patient is also complaining of tenderness where the metal button lies against the first met. Has anyone had similar problems? Can anyone recommend a solution?

Ivar E. Roth, DPM, MPH, Newport Beach, CA

RE: Scanners for Orthotic Fabrication (David E. Gurvis, DPM)
From: Multiple Respondents

The question is one that most podiatric physicians should ask.  This is one reason why my associate and I developed the STS Casting sock - to eliminate the mess and time that was required in using plaster of Paris. There have been no studies to date that document the accuracy of scanners.  The current scanners do not allow for neutral position casting without breaking your back leaning over the scanning unit.  If you purchase a scanner, you are married to the lab from whom you purchased your the scanner despite the quality of the orthotic or the price they charge. The STS slipper casting sock costs a dollar or two more than plaster, without the mess and clean up cost of plaster and of course without the $2,000-$3,000 cost of the scanner.

Richard Stess, DPM, STS, rs.sts@att.net

Scanners have been around for a long time. In Canada, it is a major way chiropractors make orthotics.  I am old school. It's all about being able to SEE neutral position. It is easy while the patient is prone, and more difficult when they are sitting, and unless you are looking up through the glass plate of some scanning systems, I think it is impossible, or at least I can't see how. And, I sure do not know how a scanner can pick up forefoot varus or valgus.
 
At last year's Midwest Podiatry Conference, I had my foot scanned and my gait recorded. The device I received was comfortable, but it seemed to offer no more support than the insole that came with my New Balance stability running shoes.
 
Here is the bottom line. If you can go to a PT, DC or shoe store and get you feet scanned, why go to a podiatrist ......to get your foot scanned. Plaster is messy. Plaster is time-consuming, but more important, I believe plaster is far more accurate, and if your lab is good, you get a fantastic device that will make you a hero.
 
Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

I have used the electronic scanning system for 5 years. Not only is there no mess to clean, it takes half the time. Depending upon the system you purchase or rent, you can still make any modification needed to customize your patient's device simply by tagging a note when sending your scanning back to the laboratory. Your patient’s gait is evaluated from heel strike to toe-off. It can be broken down to 1/16 sec frames for evaluation. You actually get to see the entire function of the foot passing through its cycle.

Modifications, if needed, are performed the traditional way: send the orthotics back and the modifications are made and the orthotics are sent back in a reasonable time frame, approximately 2 weeks.  The cost is more than the bargain orthotics one can purchase, but the bulk size is still smaller than those bargain orthotics. I have used the FootMaxx System; it has been nothing but a pleasure dealing with them as well.

Robert Nunberg, DPM, E. Boston, MA, robert.nunberg@verizon.net

RE: Frieberg's Infarction (Mitchell Wayne, DPM)
From: Multiple Respondents

One might try a bone stimulator for the avascular necrosis. Another suggestion, if contemplating a surgery, would be encasing the met head with Dermagraft. This can be done with or without an osteotomy. There are a few studies underway showing Dermagraft has been helping cartilage cells regrow. 
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

A rigid rocker sole added to the shoe is effective in treating Frieberg's. The apex of the rocker should be under the Lisfranc’s joint. MBT shoes may prove effective and can be tested on the spot.

Robert S. Schwartz, C. Ped, NY, NY, rss@eneslow.com
 

Editor's note: An extended-length letter by Dr. Sullivan appears at: http://www.podiatrym.com/letters2.cfm?id=25535&start=1

RE: Hyperuricemia Management (Eugene Batelli, DPM)
From: Gene Marlowe Barclay, DPM, Barry Mullen, DPM

If have a gouty patient in my office, and it is their first attack, once I get the pain and swelling managed, I  usually start them on a titrated course of allopurinol for 6 months.  I have the patient return at the end of that six month period and run another uric acid level.  If it is below 7 mg/dL and they are asymptomatic, I discontinue the treatment and discharge them from care.  If the uric acid is above 7 mg/dL, I tell patients they should check with their medical doctors about continuing on allopurinol or probenecid with a recommendation that the level should fall below 7 mg/dL.
 
Gene Marlowe Barclay, DPM, The Woodlands, TX, texaspod@yahoo.com

Editor’s Note: An extended-length note from Dr. Mullen appears at: http://www.podiatrym.com/letters2.cfm?id=25532&start=1

RE: Patient Grateful to DC Podiatrist Who Really Listened
From: Juliet Burk, DPM

I found this article ironic. If the patient had had the hammertoe repair as scheduled, the doctor would likely have caught the osteomyelitis during surgery, possibly offering the patient a less aggressive option than amputation of the toe. But because she went for a second opinion and the delay that ensued with the MRI, the patient did not go to the OR in a timely manner. The result was amputation. I’m happy when doctors listen, but sometimes isn’t action preferential?

Juliet Burk, DPM, Muskogee, OK

RE: Coding for the Topaz Procedure (Bruce Werber, DPM)
From: Lloyd S. Smith, DPM, David J. Freedman, DPM

Dr. Werber is wrong. Code choices are based on CPT and RUC vignettes, not simply the descriptors found in the CPT book. APMA deals with these issues daily as new and old codes are reviewed by the respective committees.  As a RUC panel member, representing APMA, I can affirm that no code for Topaz has ever been valued nor presented to CPT, and as such, no code exists. The unlisted code is the correct choice and Dr. Goldsmith is correct. Unfortunately, new technology is placed in the marketplace without the literature necessary to justify a new CPT code. Then, the company sends out its salespeople and speakers to promote the product and frequently advocates for the use of the wrong code.
 
I have no conflicts. 
 
Lloyd S. Smith, DPM, Newton, MA,  lloydpod@yahoo.com

Editor’s note: An extended-length letter by Dr. Freedman appears at: http://www.podiatrym.com/letters2.cfm?id=25538&start=1

PRACTICE FOR SALE - CENTRAL FL

Practice and medical building for sale, in beautiful, high quality of life, growing area, Central Fl.; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion & investment; good insurance climate. 352-223-2713 / E-mail: windnwave@earthlink.net

ASSOCIATE WANTED - FLORIDA

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Partnership opportunity for the right candidate. Preference given to a PSR 24+ resident completing their education this spring/summer, and must have a Florida license. Well-established practice, high tech with EMR and digital x-rays, with specialties in sports medicine, surgery and wound care. No nursing homes or HMO's. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family that is second to none. E-mail: kimvelez@tampabay.rr.com

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

PART-TIME NON-SURGICAL PRACTICE FOR SALE - NORTH JERSEY    
 
23 yo practice recently relocated to a spectacular newly-constructed and equipped storefront next to a busy supermarket with ample parking and senior citizens in vibrant downtown. Accepting Medicare and Blues only with great potential. Perfect for expanding to full-time, a second office or new practitioner with means and office experience.  Priced to sell. Financing possible. E-mail interest with contact to Mikedup1215@yahoo.com

PODIATRIST NEEDED FOR MIAMI-DADE COUNTY

Multi office practice needs doctor of podiatry for full time and/or part time for private office, clinics, and nursing homes. Great opportunity to grow with and unlimited income potential. Offices in Miami, Hialeah, Westchester, and Cutler Ridge. Email to feetdoctor@aol.com

ASSOCIATE NEEDED- SOUTHEAST MICHIGAN

Well-established practice needs to replace a departing partner and is looking for a reliable, personable podiatrist to step into a busy practice. This is an outstanding opportunity with full benefits that may lead to partnership. Please contact dr.hughes@comcast.net

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

ASSOCIATE POSITION - CHANDLER/GILBERT/PHOENIX, ARIZONA

Seeking a well-trained, ethical and hard working graduate of a PSR 24+/36 Residency to join our growing multi-location practice. This is a practice with a nice mix of 35% surgery/trauma, 20% diabetic/wounds, 25% biomechanics, 20% pediatric. ER Call. Opportunity for partnership at 2 surgery centers. Very modern offices with EMR, U/S, Digital X-Ray, ESWT, Vascular Testing Machine. Excellent referral base, and a well-trained staff. Board eligible/certified a plus. Competitive salary, bonus structure, benefits. Please e-mail CV and references to  FootAnkleAZ@aol.com

OFFICE SPACE/ MRI RENTAL – NYC, LI

Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, and Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

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