The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

April 28, 2007 #2,923 Editor-Barry Block, DPM, JD

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AL Podiatrist Offers Tips for Feet Recovering from Winter

Cold weather does not merely dry out hands, hair and lips – it also dries out feet. Though they are not often exposed, thick socks and boots can cause drying, itching and rough heels and toes, issues that take time and effort to correct. According to Dr. J.D. Smith, podiatrist at the Shoals Foot Center, different feet have different responses as summer approaches.

Dr. J D Smith

“Some people experience more dryness, while others tend to have more perspiration that develops,” he said. “Just like with other health issues, women need to listen to and know their body. In this case, it is their feet.”

Summer brings its own medical foot difficulties. Dr. Smith lists heel pain (plantar fasciitis,) Achilles tendonitis, cracked dry heels, athlete’s foot, blisters, insect bites, bacterial skin infections, warts, ingrown nails, and nail fungus as major culprits. “It is recommended that women do not wear toenail polish all the time,” he said. “Constant use of nail polish often leads to thick, discolored and fungal nails. Nail polish darkens the light to the nails as well as diminishing the normal air flow to the nails, which provides an excellent growing medium for fungal organisms.”

Source: Cheryl Myrick, Shoals Woman [4/25/07]

Smith Elected Chair of AMA RUC Committee

APMA Past President Lloyd S. Smith, DPM, was elected as co-chair of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC) April 25. In his new position, Dr. Smith will be a full voting member of the RUC, which was formed in 1991, to make recommendations to the Centers for Medicare & Medicaid Services (CMS) on the relative values to be assigned to new or revised codes in the Current Procedural Terminology (CPT) book. The RUC is comprised of only 29 members, 23 of whom are appointed by major national medical specialty societies.

Dr. Lloyd S. Smith

Dr. Smith has served as APMA’s appointed RUC HCPAC Advisor since 2004 and was the alternate advisor from 1998 to 2004. Prior to assuming the presidency in 2004, Dr. Smith served as chair of the Health Policy Committee, which is responsible for oversight of a wide range of public policy issues, including APMA’s RUC activities.

Dr. Smith, whose tenure as the RUC HCPAC co-chair begins in September, is the first podiatric physician elected as a voting member of the RUC. This represents a significant step forward for the profession because for the first time in the history of the RUC, APMA will now have an equal voice as other MD/DO specialty societies.

Source: APMA Daily eNews, [4/26/07]

BC Association of Podiatrists Names New President

Scott Schumacher, DPM has been elected president of the British Columbia Association of Podiatrists for the upcoming year. Dr. Schumacher did undergraduate training in zoology and genetics at the University of Wisconsin and is a 1987 graduate of the Scholl College of Podiatric Medicine.

Dr. Scott Schumacher

Dr. Schumacher has maintained a private podiatry practice in British Columbia for 18 years, specializing in biomechanics, surgery and the piezoelectric version of extracorporeal shockwave therapy.

The BC Association of Podiatrists has established an active provincial presence, coordinating such public events as Ask a Podiatrist, an annual free hotline, and co-producing the Live Well with Diabetes public health fair with the Canadian Diabetes Association.

Query: Severe Pain After Sclerosing Alcohol Injection

My patient, a dentist, has a neuroma and was previously seen by a podiatrist who gave him a cortisone shot, and later performed a release of the intermetatarsal ligament. I injected 1cc. of 4% alcohol in 0.5% Marcaine with epi into the foot just proximal to the area of tenderness. Three days later, the patient is called, stating that he was in severe pain and he had taken Vicodin, tried hot and cold soaks, but and nothing relieved his pain. He reports no redness, local heat or edema, or any other systemic symptoms. I instructed him to apply ice to the area where the injection was given, as well as over the tibial nerve at his medial ankle. He called back an hour later stating he had no relief and was going to give himself an injection of lidocaine. I have not heard from him since.

Has anyone heard of a painful reaction to a sclerosing alcohol injection? If so, any other ideas on treatments. The other podiatrist in my group had a similar experience a few months ago with a patient presenting to the ER the next evening.

Robert Lagman, DPM, Mandeville, LA

RE: 15 yo Girl With Posterior Tibial Tendinitis (Marc Goldberg, DPM)
From: Multiple Respondents

While I would love to recommend a custom functional ankle foot orthosis for most patients with posterior tibial tendon pathology, this case described by Dr. Goldberg reminds us that not all tendon pathology is due to mechanical overload. The tremendous focus of research on posterior tibial tendon dysfunction over the past 20 years has revealed multiple factors which can lead to inflammation of the posterior tibial tendon. An often overlooked etiology is the role of autoimmune disease and the targeting of specific antigen receptors which are located on the distal course of the posterior tibial tendon. Several excellent papers documenting the relationship between inflammation of the posterior tibial tendon and systemic inflammatory disease have been published in the literature. These include:

Michelson J, Easley M, Wigley FM and Helmann D: Posterior tibial dysfunction in rheumatoid arthritis. Foot Ankle Int 1995, 16: 156-161.
Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: its association with seronegative inflammatory disease. Foot Ankle 1989: 9: 219-225.

In the case of a 15 y/o female with three years of chronic inflammation of the posterior tibial tendon, concern should be focused on the possibility of rheumatoid arthritis as the primary etiologic factor.

Doug Richie DPM, Seal Beach, CA, DRichieJr@aol.com

I believe that tibialis posterior tendon dysfunction is pretty rare in healthy 15 yr.olds. Are there any risk factors present? Was there any history of trauma? You seem to have done everything correctly. I believe I would repeat the MRI and compare studies. Perhaps the results will influence your decision making. At this point, besides additional immobilization, consider sending your patient to a good physical therapist who understands tibialis posterior tendon dysfunction and can provide an aggressive course of physical therapy.

Otherwise, surgical exploration of the tendon with debridement and repair, and if need be, augmentation with adjacent flexor tendon will be necessary. Make sure the patient and parents are given a full disclosure-written and oral informed consent and have all parties sign it. Do not make any promises. If you don't do this type of surgery, find someone who does. In terms of orthotic selection, I have used rigid orthotics with extrinsic rearfoot varus posting, a deep heel cup and a very high medial phalange. In extreme cases it may be necessary to place her in a custom brace such as the Richey brace. .

Ira Deming, DPM, Bethesda, MD, IMDDPM@aol.com

I would suggest another MRI to determine if inflammation is still present. If not, it may be scarring or thickening of the tendon often seen in tendinosis. You may consider physical therapy, etc. If the condition does not improve, you may consider a surgical coblation of the thickened regions of the tendon using the TOPAZ microdebrider. This technique has also been investigated in conditions of plantar fasciosis. For more information, I have provided you with a link:

http://thefootblog.wordpress.com/2006/11/09/coblation-technique-in-the-treatment-of-plantar-fasciosis/

In this article, there is a link to tendon coblation and a small video showing a patellar tendon coblation.

Al Kline, DPM, Corpus Christi, TX, al@kline.net

If this young girl just had PT tendinitis, non-weight bearing for 8 weeks and PT would have helped. I think we're reluctant to pull the trigger on surgery sometimes. I'll bet she has a longitudinal tear of the PT tendon which can be difficult to see at times on MRI due to the hyperechoic fluid surrounding the tendon and sheath. I just treated a woman for eight weeks NWB for PT tendinitis, MRI (showed PT inflammation), PT with no results. I took her to surgery last week only to find a longitudinal tear from the navicular tuberosity to the muscle belly. General surgeons perform exploratory surgery all the time. We should as well if we've exhausted conservative options. Patients and family understand the general surgeon analogy very well!

Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

Editor's Note: Additional notes on this topic can be read at:

http://www.podiatrym.com/letters2.cfm?id=13844&start=1

RE: CME Challenges (Lloyd Smith, DPM)
From: Glenn B. Gastwirth, DPM

The full text of this letter From APMA’s Executive Director appears at: http://www.podiatrym.com/letters2.cfm?id=13829&start=1

NORTHERN CALIFORNIA- PRACTICE FOR SALE

Great opportunity to own a well-established turn-key podiatry practice located in modern medical office building in East Bay; Electronic billing, good payor base, no HMO contracts; Biomechanics, general podiatry with great potential for surgery. Please send CV and letter of interest to: norcalpod@hotmail.com

Seeking Resident who wishes additional training: Baltimore, MD Mercy Medical Center

Resident position CPME accredited either 12 or 24 month commitment for a highly motivated individual additional surgical training in well-established Podiatric Residency Program. Busy metropolitan hospital with high surgical numbers and inpatient care. Resident is integral member of multidisciplinary team. Begins mid June 2007. Includes competitive salary/benefits. Send inquiries to rsher18@yahoo.com

ASSOCIATE POSITION - SANTA FE, NM

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Harvard Podiatric Reconstruction and Research Fellowship Available July 1, 2007

Beth Israel Deaconess Medical Center is accepting applications for a 2-year fellowship, focusing on reconstruction of complex deformities, and an associated substantial research project. Requirements: 3+ years CPME-approved surgical residency, research interests, recommendation from residency director, CV, letter of intent, MA License. pbasile@bidmc.harvard.edu by 5/15/07.

PRACTICE FOR SALE – OHIO – SOUTHEASTERN

Reputable, thriving, well-rounded practice available with EMR. Grossing over $320K over the last 3 years. Priced to sell. Owner relocating. Email inquiries and CV to podsx@yahoo.com

ASSOCIATE WANTED – BRONX, NEW YORK

Seeking an ethical and personable Board Certified/Eligible residency trained individual (PM&S 24/36). Position available June 1, 2007 to become part of this prestigious and established NYC podiatric practice operating for 25+ years. All aspects of podiatry - Excellent opportunity leading to partnership with unlimited income potential and more. Fax CV to (718) 931-9324. WWW.BRONXFOOTCARE.COM

ASSOCIATE WANTED - MICHIGAN-DETROIT AREA

Great opportunity-must be hard-working, reliable, responsible and good with patients & staff-surgical training a plus-partnership after 1 yr. Michigan license required fax resume to 248-478-1370

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City. Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

WELL ESTABLISHED PODIATRY PRACTICE IN MT. AIRY, NC

Dr. John H. Hodges had a well established practice in Mt. Airy, NC that is either for sale or in need of an associate/partner to take over patient care. Dr. Hodges unexpectedly passed away, leaving approximately 3,500 patients. This is a unique opportunity to be able to begin work in a busy podiatric practice. If interested, contact Carolyn McMackin at (336)577-2886 or cmcmackin@triad.rr.com

PRACTICE FOR SALE - DETROIT MICHIGAN

General practice for sale. This well established muiltple location practice is grossing over $1M. Potential, potential, potential! Professional sports, acedemia, dining, and entertainment galore. Nice mix of commercial insurance, cash, Medicare. Staff willing to stay making this a true "TURN-KEY" opportunity. Contact AMERICAN DOCTOR SALES at 614-918-3000 or email sell_my_practice@yahoo.com www.americandoctorsales.com

ASSOCIATE POSITION - EASTERN NORTH CAROLINA

Multi-physician Podiatric practice looking for PSR-24/36 trained Podiatrist to join our progressive, diverse practice. High surgical volume with teaching opportunities. Competitive compensation package with definitive plan leading to partnership. Must have North Carolina license. Position available late 2007. E-mail CV and/or letter of interest to ncdpmsearch@earthlink.net

PRACTICE FOR SALE- FLORIDA

A 13 y.o. well established podiatry practice in Tavares, FL ( Lake County ) the 23rd fastest growing county in the nation. This is an opportunity not to be missed. All aspects of podiatry with hospital privileges available. PRICED TO SELL! If interested, contact Susan at (352) 406-2513 or at acrysue@gmail.com

PRACTICE FOR SALE: LA JOLLA CA (SAN DIEGO) Price reduced!

$287K '06. No HMOs, bone surgery, or insurance panels, so opportunity abounds! Affluent community. General practice, biomechanics, DME. Possible finance Serious/principals only. Cell:858-405-4780, 10-8 PDT. No Sunday calls, please. $129K Selling due to age, health problems. www.SDFootDoctor.com DrRDWorley@yahoo.com

POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

ASSOCIATE POSITION – SOUTHERN KENTUCKY

Southern Kentucky's largest and most respected foot and ankle group is looking for an associate to start in July 07. An amazing opportunity to grow with an established four provider practice on beautiful Lake Cumberland, Kentucky. Very competitive salary/bonus with a buy in opportunity will be offered. Established satellite offices will make for immediate patient base ready to be nourished and grown by a friendly, well-trained associate. Excellent benefit package. Lexington, KK is 1.5 hours North while Nashville, Tennessee is 2.5 hours South. Please fax CV to 606-679-4626.

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