June 02, 2006 #2,596 Editor-Barry Block, DPM, JD

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NY DPM Provides Advice on Keeping Feet Healthy

Folks with sweaty feet should replace the insoles of their shoes every six months, says Lori Weisenfeld, a New York podiatrist. She recommends Profoot's 2-ounce Miracle with memory foam that molds to the foot much like a mattress molds to the body. "It's the perfect thing for people who have bony feet," she says.

Now that your feet are clean and soft, you can identify corns, calluses, and bursal sacs (red and inflamed bumps) atop toes and knuckles. Corn cushions and wraps that contain mineral oil work well, Weisenfeld says. You can also see your podiatrist about having more serious corns removed.

As for bunions and hammertoes, closed-toe shoes tend to worsen them. "Those problems tend to get better when you switch to open- toed shoes, because there's less pressure," Weisenfeld says.

Source: Jessica Yadegaran, Knight Ridder Newspapers [5/31/06]

TX DPM Prepares His 3,000th Meal at Homeless Shelter

A son of an Italian immigrant, Dr. James Naples is giving people a taste of the Old Country—plate by plate by plate. Naples, a podiatrist, found his way to the Randy Sams Outreach Shelter for the Homeless to perform 250 hours of community service for a misdemeanor federal conviction for not turning over the logbooks of his airplane. Community service opened his eyes to the needs of the community, he said. A Roman Catholic, Naples also volunteers at St. Edward Outreach and has donated a building for the church's work with the poor.

Tuesday, Naples served up his 3,000th dinner for the homeless shelter's clients courtesy of recipes left to him by his Aunt Ro-Ro from Nabaleon, Italy. Naples has long since finished his community service, but still signs up to make dinners for the shelter at least eight times a month. He is also the go-to guy when someone has to cancel from their own volunteer shift—at a time when he could take the easy route of simply writing a check for someone else to sweat and toil over dinner.

All of Naples' meals are from scratch, but he keeps a ready supply in his freezer for two weeks in case of a day's notice. But with three days' notice, the clients at the shelter will be eating something fresh.

Naples is free to practice podiatry again, but he thinks if he can donate days at a time cooking meals that others can, too. He sees a real need at the shelter in people willing to pick a night to cook a meal. "I spend as much time cooking for them as I do for anyone else," Naples said. And the residents know when Naples is cooking. That brings out a smile as he has gotten to know some of the shelter's clients. "I've never not had a person come back (for seconds). I enjoy doing this for people who need it," Naples said.

Source: Lisa Bose McDermott , Texarkana Gazette [6/1/06]

CMS Publishes Medicare Payment Ranges Online

The CMS published online what Medicare pays for the 30 most common elective procedures at hospitals, describing the effort as a first step toward making the cost of healthcare services more transparent to the public. The agency posted zipped Excel files containing county-by-county payment ranges for fiscal 2005 for the top 30 DRGs and the number of cases treated at individual hospitals. It also posted data for other high-volume in-patient DRGs.

HHS Secretary Mike Leavitt said officials hoped more insurers and providers would follow the federal example and make price and quality information easily available to the public. President Bush ordered the data be disclosed as part of his push for more consumerism in healthcare. The CMS expects to post payment information for ambulatory surgery centers later this summer and for hospital outpatient departments and physician offices this fall.

Source: Matthew DoBias, Modern Healthcare [6/1/06]

Query: Articles on Efficacy of Orthotics

I am fighting CIGNA for coverage of orthotics. I have a 25 yo patient with a moderate bunion, and prescribed custom orthotics prior to deciding to move forward with surgery. The conservative first approach. They want literature that proves efficacy in treating bunions before they will approve the devices. Does anyone have these articles available?

Howard Schultheiss, DPM, Bel Air, MD

RE: MPJ Pain While Squatting (Jeffrey Kass, DPM)
From: Multiple Respondents

This sounds like a classic case of hallux limitus or functional hallux limitus. When most people squat they lift their heel off of the ground, especially with ankle equinus. This creates a demand for dorsi-flexion of the MPJ, which in this patient hurts. A reverse Morton's extension (extension under mets 2-5) can be very helpful for this problem as it decreases the stress on the windlass mechanism in the squatting position. Orthotics would contribute to the reduction of stress during walking, which may be helpful for squatting, but the hole under the first met will really help when squatting.

Eric Fuller, DPM, Berkeley CA, efuller@lifelongmedical.org

I know from personal experience that orthoses can be effective in treating pain associated with squatting. I developed sesmoiditis in my early forties as a result of squatting in the catcher's position while coaching baseball. I was able to treat the condition with orthoses, even though it wasn't gait-related.

Dr. Kass indicated that the patient has a hypermobile 1st ray, a term that is typically used to describe excessive dorsi-flexion of the 1st ray. Before making any treatment decision, I would recommend examining the open-chain range of motion of the first ray, the open-chain range of dorsi-flexion of the hallux, and the anatomical length of the 1st metatarsal. A metatarsus primus elevatus and/or a congenitally long 1st metatarsal can be associated with 1st ray
hypermobility and functional hallux limitus. Your patient may be experiencing hallux limitus and associated jamming at the dorsal aspect of the 1st MPJ. If the patient has an adequate open chain range of hallux dorsi-flexion, I would consider treating for functional hallux limitus.

There are a number of orthotic modifications that can be useful in the treatment of functional hallux limitus. Since this condition is associated with squatting, I would focus on those modifications that might improve 1st ray plantar-flexion and hallux dorsi-flexion while in a squatting position. Casting the foot with the midtarsal joint fully pronated and the 1st ray in the neutral position can improve 1st ray stability and assist with 1st ray plantar-flexion in an orthosis that is intrinsically or extrinsically posted in the forefoot. As long as there is pressure on the metatarsal heads, the corrective influence of forefoot posting will occur because there will be force borne on the distal aspect of the orthosis.

Using either a reverse Morton's extension or a varus forefoot extension with a 1st metatarsal cut out can also assist with 1st ray plantar-flexion relative to the 2nd metatarsal, in order to improve the functional range of hallux dorsi-flexion. There may be adaptive changes in the MPJ before the condition completely resolves. It is also important to differentiate a structural hallux limitus, in which case surgery may be indicated.

Jeffrey A. Root, President, Root Lab, jroot@root-lab.com

If you are unsure whether a Morton's extension would work or not, try making him one out of felt and taping it to the foot. Have him squat in the office with and without the pad and then have him use it for a day or two at work. If it helps then you can make him an orthotic with the correction.

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

I usually try a first ray cut out first. However, if that is not successful, then I switch to a Morton's extension. You can avoid having to make two different orthotics by having the patient experiment with a 1/8-1/4 inch felt build up under 2,3,4,5 met heads, if that helps then I go with the first ray cut out. If that doesn't help then I have them try strapping the first MPJ to limit
dorsiflexion, if that helps then use the Morton's extension. A rocker-soled shoe might also help.

Ken Meisler, DPM, New York, NY, Kenmeisler@aol.com

RE: Competitive Acquisition Program for DME (Lloyd Smith, DPM)
From: Paul Kesselman, DPM

Dr. Smith's response, that attempts by CMS to put bidding systems and/or a pre-certification system in place, is unfortunately true. This, however, is not healthy for us as providers, nor will it be for us as patients.

The message needs to go out to both patients and providers that this is an unacceptable system which will ultimately cost the system more and injure many patients. If we sit back and allow this to happen, these schemes will become endemic for the entire healthcare system, including all non-Medicare insurances as well as Medicare carriers.

If allowed to progress I can envision the following scenarios: My bid on 11720 is too high, and that of 11055 is accepted, so I can trim the callus on my patient, but the patient has to go to another provider for their nail care?

Sorry, but this provider says it is just unacceptable to sit back and accept!

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

ASSOCIATE WANTED - NEW YORK

Associate Wanted - Rockland County, Rockland County. Associate with minimum 5 years experience, high volume established general practice. Reply with CV to nypodiatry111@aim.com

ASSOCIATE WANTED - MINNESOTA – MINNEAPOLIS SUBURB

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with buy-in opportunity. Looking for PSR 24/36 trained individual, to help increase surgical volume. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

1st YEAR RESIDENT SLOT AVAILABLE - CALIFORNIA

Sherman Oaks Hospital, in Sherman Oaks CA, has a (PM&S-24 I 1st. year) program available, beginning 7/1/06. Our program offers the Residents a wide variety of cases from ankle fractures, subtalar joint, fusions, & tendon transfers as well as all other podiatric forefoot & rearfoot cases, with very impressive procedure activity numbers at a "C" level. The Residents meet & exceed the requirements for surgical case loads, usually by the first 6 months. Residents will also see an average of 250 to 300 wound patients per month.

The stipend for the 1st year Resident is Thirty Thousand dollars ($30,000) and 2nd year Resident; Thirty- Four Thousand dollars ($34,000). For more information please call Dr. Boghossian at (818) 905-2222 or e-mail him at gbogi@sbcglobal.net

PRACTICE FOR SALE – ARKANSAS

Thriving Ozark Mountains practice in prime retirement area seeks to sell on long term note. Two locations: Mountain Home and satellite office in Harrison, Arkansas, both with established patient base with full range of services and nursing homes available. Hospital privileges. Wonderful Staff. Fully equipped. Priced to sell. (870) 425-1466 orchristinag@centurytel.net

POSITION WANTED - NEW YORK

Non surgical podiatrist with 20 years experience is seeking practice opportunity 1-2 days/wk. ABPOPPM board certified, own malpractice insurance, many insurance plans. Please call (516) 557-6862 or e-mail Joelme@aol.com.

ASSOCIATE POSITION- NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

EQUIPMENT FOR SALE - ESWT

If you are using or thinking of using ESWT, I have a new machine that has only been used twice. There is no Orbasone in the country priced like this one. Will provide training and installation. Take a look at http://www.orbasone.com Call 1-856-229-2939.

POSITON AVAILABLE - WASHINGTON, DC

The George Washington University Medical Faculty Associates, a large multi-specialty practice affiliated with a teaching hospital, is seeking a full-time podiatrist. The practice has a diverse population encompassing inpatient and outpatient surgery, as well as a thriving outpatient clinical practice. Must be board certified/board eligible and have experience in diabetic limb salvage. Send CV to cdugan@mfa.gwu.edu or fax to (202) 741-2241.

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