The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

April 15, 2010 #3,832 Publisher-Barry Block, DPM, JD

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Tragedy is That Diabetes Amputations are Preventable: AZ Podiatrist

The vascular clinic at University Medical Center offers a glimpse into the future for those affected by childhood obesity. People come in wearing orthopedic shoes and missing limbs. Many are seriously ill with end-stage diabetes and spend hours every week in kidney dialysis. About 95 percent of the clinic's diabetic patients have Type II diabetes, says podiatric surgeon Dr. David G. Armstrong, who directs the Southern Arizona Limb Salvage Alliance, and works in the clinic with vascular surgeon Dr. Joseph Mills. "If there were an evil deity trying to figure out the worst possible disease, it would be diabetes. It is a disease that is silent in so many ways," Armstrong says. "It's not like a heart attack, where people drop right away."

Dr. David G. Armstrong

Armstrong says the biggest tragedy with the diabetic patients he sees is that so many of the cases are preventable. The saddest thing about so many of the patients in the clinic is that they don't feel pain the same way the rest of the population does. That means they don't notice when infections are eating their bones, and sometimes the infections become so advanced that the limb is lost.

Source: Arizona Daily Star [4/12/10]

CA Podiatrist Opposed to Barefoot Running, With Limited Exceptions

The podiatric community is unanimously opposed to running barefoot. They argue that running shoes were designed to protect our feet from ground conditions and sharp objects and provide shock absorption from running on hard surfaces; thus, preventing both acute and chronic injury.

Dr. Steven Rosenberg

Dr. Steven Rosenberg, a holistic podiatrist based in Santa Monica, California, explains that the foot is comprised of 26 small bones with multiple joints. Without the support and cushioning of appropriate running shoes, runners become vulnerable to a multitude of overuse injuries, such as stress fractures, tendinitis, plantar fascitis, metatarsal bursitis, and others.

Dr. Rosenberg adamantly states that the only safe option to running barefoot would be to do so on soft sand; however, even then, one would need to be cautious of any sharp objects below the surface.

Christine Kwok, PMLA Triathlon Examiner, {4/11/10]

Bell Named Chair of CCHIT

Karen Bell, has been named to succeed Mark Leavitt, as chair of the not-for-profit Certification Commission for Health Information Technology, Chicago, the organization has announced, effective April 26. Bell, most recently served as senior vice president of health IT services at Masspro, Waltham, MA, a Medicare quality improvement organization, and previously served within the Office of the National Coordinator for Health Information Technology at HHS as director of its Office of Health Information Technology Adoption. While there, she served as the ONC's representative to the CCHIT board of commissioners from 2006 to 2008.

Dr. Karen Bell

Like Leavitt, Bell is a physician. She is a graduate of Tufts University School of Medicine, Boston, with a specialty in internal medicine. She has served as an associate professor at the University of Rochester and a clinical instructor at Harvard University School of Medicine.

Soource: Joseph Conn, Health IT Strategist [4/12/10]

Query: Tissue Glue for Fissures

Can anyone recommend a tissue glue for deep heel fissures, or will any superglue work? Also, how deep into the fissure would you apply it.

Sam Rosen, DPM, NY, NY

RE: Stiff Joint, Post-op Bunion Surgery (Mathew M. John, DPM)
From: Barry Mullen, DPM, Carl Solomon, DPM

Did I misread Dr. John's initial post? I believe it implied that he immediately allowed his patients to ambulate after osteotomy surgery completely unprotected from day one. That intimates either barefoot walking or walking in a soft-soled shoe, like a sneaker. In his latest reply, he indicates that he ambulates them in a post-op surgery shoe x 2 weeks. That is a completely different scenario and certainly not unprotected weight-bearing; so, there's little issue, though I believe that for some patients, for some distal 1st metatarsal osteotomies, a post-op surgery shoe may be inadequate, and so might the two-week time frame. Issues arise if one performs a precision osteotomy for realignment of the 1st ray and expects AO fixation, of any kind, to solely maintain that correction and stability without some form of weight-bearing protection. The amount of time necessary varies with several factors, including but not limited to physiologic patient age, bone stock quality, type and locale of osteotomy performance, AO fixation performance and its effect on osteotomy stability, as well as several systemic factors that might negatively affect bone healing.
 
As for wound dehiscence following early passive ROM exercise intervention, from my experience, this has been a rare exception, not the norm. My patients are generally advised to wait until their initial acute pain response wanes, generally 36 hours and then begin this process from that point forward. When they are seen on post-op day 4 or 5 for wound check, the 1st MTP ROM is assessed. If I believe that they are already well behind "the bell curve" for 1st MTP dorsiflexion norms, generally from "over-babying" their foot, they are referred to P.T. as soon as sutures are removed (generally day 11 or 12). Post-op 1st MTP stiffness, in the setting of proper osteotomy and fixation performance, with early passive ROM, has been a very rare complication. In general, if the osteotomy is properly aligned with respect to the 1st ray's sagittal plane axis, most patients actually attain more post-op ROM than they had pre-op.
 
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

I don’t know that there’s a single common denominator in the development of limited 1st MTP joint dorsiflexion after bunion surgery. Much of the discussion has focused on the joint capsule, whether or not there’s fibrosis, how the articular surface is re-contoured, the effect of early motion, etc. There’s a factor which I haven’t seen mentioned, and in my mind (but have never seen it studied), is more plausible. We make a science of analyzing hallux limitis/hallux rigidis. One of the recognized etiologies is an elevated first ray. I would take the position that, in some instances, bunionectomies that include 1st ray osteotomy have the inadvertent effect, however subtle, of lifting the 1st metatarsal head. I suspect this may be accentuated somewhat with premature and insufficiently protected weight-bearing. If that be the case, range-of-motion exercises, physical therapy, etc. for post-bunionectomy joint stiffness would have no more a long-lasting effect than the same approach for virgin hallux rigidis.   
 
Carl Solomon, DPM, Dallas, TX, cdsol@BaylorHealth.edu

RE: MASS Theory (Doug Richie, DPM, Kevin Kirby, DPM)
From: Edward Glaser, DPM, Rob McClanahan

I might suggest that Dr. Richie is an expert with commercial interests too, as is Dr. Armstrong. Not that being in business is a bad thing.  Yes, patients do generally have better results with MASS posture orthoses. I could not agree with you more about research. Here is a...

Editor's Note: Dr. Glaser's extended-length letter can be read here.
 

While we are discussing whose theory of biomechanics is right, and what is the gold standard way to capture neutral impression casts, our new APMA president gives the green light on 2 inch heels. So, does it really matter how you capture your neutral impression? No, it does not. Because your orthotics are rarely, if ever, going to function from the flat surface you conceptualized when you took your casts.

Most of the time your orthotics are going to function...

Editor’s note: Dr. McClanahan’s extended-length letter can be read here.

RE: MASS Theory  (Kevin Kirby, DPM)
From: Edward Glaser, DPM, Carl Solomon, DPM

If only credentials made someone right. I have never put M.E. after my name. If I had that degree, I certainly would. I do have five engineers at Sole Supports, Inc. of various specialties, and am searching to hire another (not to mention the Vanderbilt biomedical engineering interns who rotate through our facility every year). I studied mechanical engineering in college, but since I had switched from biology at the end of my NY Regents Scholarship, I had not completed my ME degree. I got a job with Sperry Gyroscope for two years, where I worked assisting ME’s on cabinet design for Navy radar systems. I then went back to school. 

Instead of finishing the ME, I finished my last requirements for podiatry college and was accepted. Then, to save up some money, I worked for another six months for an engineering company sub-contracted to help build a nuclear power plant, where I inspected reactor piping. The summer before podiatry college, I hitchhiked with my guitar to Nashville to volunteer with the Appalachian Student Health Coalition, delivering medical care to the poor rural population of the mountains of east Tennessee. Then I went to NYCPM. If you would like more personal history of my life,  please feel free to ask. Some people just can’t wait for my auto-biography to come out.

Additionally, I challenge Doug Richie, Paul Scherer, and Kevin Kirby to a debate live on the Internet or in person.

Edward S. Glaser, DPM, CEO Sole Supports, Inc., ed@solesupports.com

Who knows about Dr. Glaser’s “MASS" theory?  He’s come up with something that makes sense to him. Root’s approach has been historically entrenched in podiatry and makes sense to a lot of us.  But “makes sense” doesn’t cut it, despite what our theories are.
 
Until a valid and reproducible study on the effectiveness of orthotics is published, I think it’s unreasonable to criticize Dr. Glaser’s approach just because the Root theory has been the conventional norm. From an evidence-based viewpoint, we can’t say that Root wasn’t wrong and MASS theory is right.
 
I’m not familiar with many studies dividing a large patient population into a “received orthotic group” and a “didn’t receive orthotic group”, then assessing them after a significant time period for some sort of end point. That end point could be whether or not a bunion recurs after surgery… whether an early bunion progresses… whether IPK’s respond…whether shin splints disappear…if “predislocation syndrome” gets better…etc.  Without that, the entire basis of our use of orthotics is purely anecdotal, and this argument will never end.
 
I think the same can be said about “foam box” vs. plaster casting for orthotics. We just don't know.
 
Carl Solomon, DPM, Dallas TX, cdsol@BaylorHealth.edu

RE: Radiology Lab Performing Neuroma Injections
From: Elliot Udell, DPM

In my geographic area, there is a huge radiology lab that now advertises that they are offering foot injections for neuromas. I have choices where I can send people for MRI's and other studies. This radiology company that is taking patients away from my colleagues as well as me is not one that I will readily send patients to for radiology studies. I hope that my local colleagues share this concern.
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Skating Boot Problems (Nancy A. Kaplan, DPM)
From: Juliet Burk, DPM

As an adult-onset figure skater, orthotics user, and podiatrist, I have a little experience with this one. Stretching a skate boot is nearly impossible. Ask any boot shop. Skate boots are made out of the most rigid leather you can imagine because skates are designed to maintain their stiffness. And as the mother of three teenage boys, I never give up on smells, especially since the cost of replacing a figure skating boot is typically in the $600 range for even moderately competitive skaters. Boots are usually worn until they completely give out, and attempts are often made to refurbish them and keep them going even longer. I like to take mother nature’s solution for odor—good old sunshine. 

Opening up any shoe or boot for a good airing and using nature’s UV ray gun (direct sunlight for several hours) usually cures moldly AND bacterial laden shoes. Yes, it’s true. A few hours of direct sunlight and I can hold my sons’ worst shoes directly to my nose without passing out OR detecting odor. On Your Toes is a product that also works well if you insist on spending money (or receiving money as the case may be). And while I have never attempted fitting a custom orthotic into a skate, I have used Comforthotic felt insoles from Hapad for the modest price of $16/pair for the last two years in my skates with great success. It maintains proprioception very well. It’s a bit tricky to get them to lie perfectly in the shoe, but I believe in trying the least expensive things first.

Juliet Burk, DPM,  Muskogee, OK, juliet-burk@cherokee.org

RE: Orthotics for Ice Skates (Joel Morse, DPM)
From: Jeff Root

In my experience, ice skating orthoses are used for one or a combination of the following reasons: a) to alleviate symptoms, b) to improve comfort, or c) to enhance athletic performance. Several years ago,...

Editor's note:  Mr. Root's extended-length letter can be read here.

RE: FL Podiatrist's License Suspended for Unpaid Student Loans
From: Philip E. Larkins, DPM, Tip Sullivan, DPM

“Wow!” is my remark, after reading that poor Dr. Shariff had his license indefinitely suspended for lack of payment of student loans. I always liked Dr. Shariff during podiatry school; he even was a candidate for the Iraqi presidency at one time! I find it comical that, in the USA, we throw people who don't pay their bills into the husecow! How ridiculous really. Think about it, if someone (a doctor) owes money on their student loans, does it really make sense to take away the only livelihood that they know? How much money will you get from the scofflaw then? It is not much to worry about though; soon enough, we will all be working for free after a few more Medicare reductions.
 
Philip E. Larkins, DPM, Escondido, CA, larko33139@yahoo.com

First, may I say that I pay my bills and expect everyone else to do the same. I am not in favor of ducking unpaid student loans. In fact, I lean more toward the whipping post for those that are able to pay and do not!  Let the lender of the money take the guy’s house or belongings. At the same time, I really hate it when the government or one of their branches (podiatry board) sticks their nose in places that I don't think it belongs. If the board of podiatry can jerk a license because of an unpaid student loan, maybe the next thing they will do is start jerking your license when you have too many parking tickets.

This smells like another one of those times that the podiatry board (Uncle Sam) has stepped over the line. 
 
Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net

RE: Accountability of Expert Witnesses  (Richard W. Boone, Sr.)
From: Ira M. Baum, DPM, Allen Mark Jacobs, DPM

I respect Mr.. Boone and enjoy his posts on PM News. Regarding expert witness position, he astutely identifies that there is no method of retribution against these expert witnesses other than whipping them in court until plaintiff attorneys no longer want to use them.  A real pity because then the plaintiff attorneys have to spend time, money, and energy to find the next expert witness who is willing to make a living stretching the boundaries of negligence to make a living. I believe Mr. Boone is quite aware, that beating them in court does not solely depend on the plaintiff’s expert witness, and there are times these expert witnesses are not adversely affected by the decision made in the court room. 

Unfortunately for the podiatrists who are being sued and the healthcare system in general, we are all hurt because of their greed. Regarding the sacred and important Constitutional right to freedom of speech, this is one case in which using words to weave a web of reason to fulfill their own needs is damaging to our society. 

Ira M. Baum, DPM, Miami, FL, ibaum@bellsouth.net 

Once again, the subject of the "expert witness" in medical negligence cases elicits response from the PM News readers. I would like to offer some potential solutions to the problem other than those suggested by the highly respected Mr. Boone.

There is an organization called Medical Justice...

Editor's Note: Dr. Jacobs' extended-length letter can be read here.

RE: Coding Reaches New Heights

Gucci shoe

Should This be coded as a L1930, L1951, or L1971? I can't tell if the hinge is rigid or not.
 
Source: Ad in NY Times [4/11/10] via Ron Werter, DPM

ASSOCIATE POSITION – NEW YORK

Podiatrist Needed Immediately - RFC only. $45/hr working for the state prison system. Clean and safe. Easy money to help pay the bills. Several shifts available. If interested, E-Mail hansfeet@aol.com

HOME FOOT CARE PHYSICIAN NEEDED-LOS ANGELES, CALIFORNIA

Honest, caring, hard-working podiatrist needed to make visits to homebound patients, facilities, etc. for Home Foot Care, Inc. Part-time position, flexible hours, independence and excellent compensation. If interested email CV to homefootcare@hotmail.com or call Terri at 323-353-8103.

ASSOCIATE POSITION – MICHIGAN

Well established practice in Southeast Michigan suburbs seeking full time associate. Must be ethical, personable and professional. This is a solid opportunity for a PSR-36 graduate or experienced practitioner. Must be able to diagnose and treat everything from general podiatry to reconstruction of severe deformities of the foot and ankle. The practice is currently maintained by two board certified surgeons. This practice is residency affiliated. Please forward current location and availability with C. V. to HKANEDPM@gmail.com

CANADIAN PODIATRISTS COME BACK HOME!

An Edmonton, Alberta group of DPM’s requires an additional Podiatrist. Interest in biomechanics essential. Given Canadian visa restrictions, this position is open only to Canadian Citizens or permanent residents. Very attractive compensation package. Fax C.V. or letter of interest to: (780) 483-5796.

ASSOCIATE POSITION FULL-TIME - SUBURBS OF CHICAGO

PSR 36 - month-trained podiatrist needed for busy suburban Chicago practice. Full benefit package included. If interested, please email your curriculum vitae to foot1st@yahoo.com

PRACTICE FOR SALE: TENNESSEE

Established 30-year full-scope podiatry practice. Excellent hospital and surgery center privileges with investment opportunities. Fully equipped 2200 sq.ft. office across from hospital. High volume of new patients, DME, and local referral base. Great community for a family and the outdoorsman. Reply to tnfootdr@gmail.com

ASSOCIATE POSITION - TEXAS

Dynamic, growing practice in Dallas/Fort Worth area, seeking surgically trained, Board Certified/Board Qualified Podiatrist. Excellent salary and benefits compensation package, for the right candidate, with partnership/buyout opportunity. Contact/Send resume to: jmh6122@yahoo.com Texas Podiatry License Required.

ASSOCIATE POSITION - SOUTHWESTERN PA

Suburban Pittsburgh. To work in an established practice and also a new office scheduled to open in August 2010. Future partnership buy-in possibilities. Rearfoot credentials needed to expand the established practice, and to maximize the potential in the new practice. Competitive salary, benefits. 724-337-4433.

ASSOCIATE POSITION - SW FLORIDA, BEACHES

Well-established podiatry practice with excellent mix office/surgery seeking full-time associate PSR 12-36. Excellent salary & benefits for the right hardworking, personable candidate. Email resume to capecoralpodiatry@live.com or fax to 239-573-9201

PRACTICE FOR SALE - MAINE

20+ year full scope turn-key practice in the same medical building, podiatrist-friendly hospitals nearby, appreciative and cooperative patients, excellent expansion potential. Retiring seller will stay for transition. mainefootdoc@yahoo.com

PRACTICE & BUILDING FOR SALE - MIDDLE TENNESSEE

Two locations each with 3 exam rooms, x-ray room, large waiting room, and ample parking. Excellent locations and growth potential. All equipment and furniture included. Website and marketing material included. Seller happy to assist with transition. Priced to sell with financing available 250k. Call 931-446-5724.

ADVANCED RESEARCH AND SURGICAL FELLOWSHIP

Boston University Medical Center has two unique fellowship positions Become an expert in Limb Preservation, Tissue Repair and Regeneration. Be part of this unique Fellowship at a major teaching facility. During this time, he/she would be expected to become a knowledge expert who will contribute significantly to research, surgical procedures, teaching, and innovations in limb preservation and tissue repair. Requirements: Completion of a two or three year surgical residency; Candidate must possess a commitment to an academic career in podiatric medicine and surgery. Annual Salary: Year 1 $61,000, Year 2 $66,000. Submit a CV and letter of interest to: erin.springhetti@bmc.org

ASSOCIATE POSITION – CALIFORNIA

Looking for a motivated podiatrist to join a rapidly growing practice in Los Angeles. Will hire immediately. Excellent compensation. Please fax CV to: 310-652-3669.

FULL-TIME PODIATRY OPPORTUNITY - BOSTON, MA

HealthDrive is seeking a caring podiatrist to join our group practice. We currently have a FT non-surgical opportunity available in the Boston, MA area. We offer a competitive salary, Paid malpractice Insurance, health and dental Insurance, long & short term disability, flexible schedule (No weekends), established patient base, equipment, supplies and complete office support provided. If interested in this opportunity, please call Maria Kelleher (toll free) at 877-724-4410 or email caring@healthdrive.com

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

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