The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

June 26, 2009 #3,581 Publisher-Barry Block, DPM, JD

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IL Podiatrist Provides Summer Foot Care Advice

Those strappy shoes you love so much can have a downside. They create friction that, combined with the usual dryness of the skin on the bottom of your feet, can cause cracked heels. In extreme cases, your feet can bleed or become infected, says Helena Anne Reid, a podiatrist in Moline, IL.

Dr. Helena Anne Reid

Solution? "Use a pumice stone on your heels every day in the bath or shower, then find a cream you like and put it on your feet twice a day," says Dr. Reid. She adds, "If an over-the-counter cream doesn't help heal cracks, talk to your doctor about a prescription product." Protect your feet further by alternating between wearing sandals and closed shoes. And don't walk barefoot outdoors.

Source: Quick & Simple Magazine [June 2009]
 

CA Podiatrist Discusses Plantar Fasciitis

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 via SHNS [6/23/09]
 

PRESENT Presents at HCMA Meeting

Alan Sherman, DPM and Michael Shore, DPM, founding members of PRESENT e-Learning Systems, delivered a model of what medical education could look like in the near future to a packed room full of pharmaceutical and medical device executives. Their presentation at the recent Healthcare Communications and Management Association’s (HCMA) annual meeting held in Jersey City, NJ focused on adding social networking features to online medical education.

Dr. Alan Sherman, Diane Krusko, Marketing Director of Pfizer, and Dr. Michael Shore

Sherman reviewed the explosion of social networking use around the world and demonstrated a model for recreating the live clinical conference education experience with currently available Internet social networking tools.

When Patients Need X-Ray Copies, Give ‘em a CD

In the past few years, it has become commonplace for patients to bring in CD’s with MRI's or CT’s, and more recently, x-rays. The new digital x-ray technology has made this possible. It’s very easy to make a digital image of a conventional film using a digital camera, then copy it to a CD. CD’s are cheaper than x-ray copy film and the process is clean and quick. In addition, you can clean up an otherwise poorly exposed film.

Original Photo of X-Ray

The following tips should be helpful. When photographing an x-ray, you must disable the flash on the camera. Set the camera on macro mode (the icon with the little flower). If the camera uses the center portion of the viewfinder to set exposure, point it at a part of the x-ray that is neither real bright nor real dark, and press the button down 1/2 way before you re-compose and take the picture.  Stabilize your hand (or use a small tripod) and push the shutter release button real slowly. When you save the edited file, rename it so that the original file remains intact.

Photo of x-ray after editing

Photoediting software that comes with Windows or your camera can correct for a multitude of errors by adjusting brightness or contrast. 

Source: Carl Solomon DPM, Dallas TX, cdsol@baylorhealth.edu
 

Query: Heel Pain in Runner
 
I have a 74 year old marathon runner who has just had to cut her distance from full to half marathons due to heel burning. She has no allergies, takes no medications, and has never been hospitalized. At 5 miles, her heels begin to burn, and then the skin peels. She has not noticed any true blistering. The pain gets so bad that she ends the race running on her toes. Her shoes fit well. Biomechanically, she is WNL. There is no equinus. No corns or calluses anywhere else. No heel fissures. No fat pad atrophy. She wears Saucony running shoes and discards them at about 250 miles. I am tempted to put her into orthotics on an empirical basis. Anyone have any thoughts on this?
 
David E. Gurvis, DPM. Avon IN

Query: Platelet Gel

I've tried to find a vendor to supply me with the equipment to use platelet gel in the office and have been unable to do so. Do my colleagues have a name or company they can share? 

Sloan Gordon, DPM, Houston, TX

RE: Drop Foot (Richard Hofacker, DPM)
From: Multiple Respondents

For you youngsters out there, Saturday night palsy is when a drunk would fall asleep on the park bench with one arm over the back upright of the bench and wake up in the morning with a compression palsy. This can happen, and is called crutch palsy when a patient leans incorrectly on a pair of crutches in the axillary area.
 
I  suggest this has happened to your alcoholic patient.  Although you or he may never know what position he “fell down drunk into”, it appears pretty obvious this could be a cause, especially with the rapid onset of symptoms. Possibly, the common peroneal nerve was damaged but that is just my hypothesis.
 
I strongly suggest a referral to a neurologist, not to mention AA. Insurance or not, improper treatment of this patient by refusing a referral based on financial considerations could be construed as negligent. If the patient declines, document this refusal. It is also within your purview to suggest AA or a similar program.
 
David E. Gurvis, DPM,  Avon, IN deg1@comcast.net

This sounds like it may be an acute compartment syndrome. The patient probably passed out and had pressure on his lower, and possibly upper leg, affecting the peroneal nerve. If the swelling has gone down, he may not need a release of the lateral compartment. He might benefit from an injection to the peroneal nerve near the fibular head, if you can do that in your state. Something needs to be done ASAP for him so that he can potentially improve from this or he may be debilitated for the rest of his life.

Bruce Williams, DPM, Merrillville, IN, bwilliams@airbaud.net

This sounds like the patient has a common peroneal nerve palsy, common in alcoholics who pass out with their legs crossed, causing prolonged pressure on the common peroneal nerve where it emerges superficially just below the lateral knee. It’s self-limiting, most of the time. If a brace and improved nutrition is not effective, surgical exploration of the fibular tunnel is indicated.

Howard R. Fox, DPM, Staten Island, NY, foxhr@yahoo.com

RE: Neuropathy From Chemotherapy (Jim Benedict, DPM)
From: Multiple Respondents

Neuropathy from chemotherapy can sometimes be so intense that it becomes the most debilitating side-effect. Besides intense tingling, burning, and numbness, it can interrupt sleep and create anxiety far beyond other side-effects. I've had patients come in crying that they can't sleep, can't walk, can't eat and are mentally exhausted. High dose Neurontin (up to 3000 mg daily), might calm it down slightly, but it comes with many side-effects. 

A change to Lyrica might be an alternative choice, but it usually isn't enough. I would stay away for Cymbalta. Studies show that it could bring on suicidal intentions, and that's the last thing you want to do in this situation. 

I know that there has been some controversy over the use of B-12 (cyanocobalamin) lately, so this is a good test for the effectiveness of the treatment. I usually mix 1cc of cyanocobalamin with 0.5 cc of triamcinolone (20mg), and 1.5 cc of 2% lidocaine plain. I would give a therapeutic nerve block to the posterior tibial nerve with this 3cc combination in both feet. Keep them on the Neurontin and the Zoloft, and have them come back in a week. I usually give a series of three in one or two week intervals. If it works, you're a hero, and if it doesn't, the patient is happy that you tried something. It has been my experience that it ALWAYS WORKS. 

Randy Bernstein, DPM,  Dearborn Heights, MI, foottdude@sbcglobal.net

The most important aspect of this clinical history to determine appropriate therapy which was not mentioned, is does the patient have pain? If the answer is no, then none of the medications should be used. Neurontin, Lyrica (which are in the same drug class and should not be used together) in addition to Cymbalta are all for painful neuropathic symptoms. Zoloft is not an effective drug for painful neuropathy. Painless neuropathy, especially one caused by a toxin (chemotherapy), is unlikely to resolve. Since the patient can not feel the Semmes-Weinstein monofilament, she is at risk for foot ulceration. Supportive therapy by preventing ulceration with education, footwear, and perhaps home thermometry should be recommended.

Lee C. Rogers, DPM, Des Moines, IA, lee.c.rogers@gmail.com

I have had success treating all forms of neuropathy utilizing nutritional medicine and MicroVas therapy. When used properly in the protocol, MicroVas makes a big difference in outcome.

I have no financial relationship with the company, but have given lectures on its benefits.

Bob Kornfeld, DPM, Manhasset, NY, holfoot153@aol.com

RE: Time Clock/ Management Software (Stuart W Kushel, DPM)
From: Multiple Respondents

TraxTime is easy to use and affordable ($39)
(spudcity.com/traxtime/index.html)

Alan Kalker, DPM, Middleton, WI, ajkalker@wisc.edu

Here is a simple solution. It is free for up to 3 employees. And very cheap if you need to purchase it. You can either use it as a server-based program or put the program on individual computers.

(lionclocksoftware.com/standard_info.html)

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

We have been using a program called Timelot for the past 5 years. It can be loaded on a laptop as a client, has editing capabilities and is easy to use. The biggest problem with this or any time-keeping software is it only works if you use it. We still have issues of people not “clocking” in or out and then we need to make adjustments in the timekeeping management portion of the program. But as far as simple and low cost, it meets the goal and you can add up to over 100 employees. The website is timelot.com and a brief description is below. I know they have added features since we got it years ago but have never upgraded and have never had a problem with it.

Brooke Weaver, Central Kansas Podiatry Associates, Brooke@ksfootdoc.com

RE: Wound Care and Nursing Home (Ashley A. Keren, DPM)
From: Multiple Respondents

I think Dr. Keren brings up a common dilemma that many of us have encountered over the years in an inpatient (e.g. nursing home, rehab facility, etc...) setting. The first piece of advice I would offer: NEVER pretend you don’t see a wound!! I would document the wound in your initial assessment regardless of why you were consulted. If treatment has already been initiated, I typically make note of it and defer to the ongoing treatment (unless I see gross neglect or improper treatment).

Now, whether or not to treat it is dependent on the doctor who consulted for your services. I have found that educating the attendings is the ONLY way to ensure you get a proper consult (e.g. "Consult Podiatry for Evaluation and Treatment of Foot Ulcer" vs. Consult Podiatry - toenail cutting). If the consult is for routine foot care, it is my opinion that you are initially bound to that request, HOWEVER, you can pick up the phone and contact the requesting doc and discuss the care of the patient. I would not let the "wound nurse" dictate how you practice. I always tended to befriend these in-house ostomy nurses, gain their trust and they will be on your side and lean the attending to consulting your services if needed. Also, another face-to-face meeting (in service) with the administrator and wound nurse may provide them some insight as to your qualifications and expertise in the wound care field.

Lastly, I have worked in at least 8 different "nursing homes" over the years, all under different management, and you are not in the minority for being treated this way BUT it is your obligation to at least try to educate them on your training and abilities to treat the patient.

Mitch Barber, DPM, Laurel, MD, mbarberdpm@gmail.com

There are times when I am consulted in the hospital and the orders are to take care of the ingrown nail. I get there and there is an ulcer or other major condition I could treat. I check the chart and see that the major problem was referred to Dr. Debrider our general surgeon and honorary "wound care" specialist. I would love to get on the overhead paging system and say "Don't you know what I do?" but that is not the correct way of handling things. I do my consulted work and then make note of the ulcer in the record's physical exam as well as my understanding of its current treatment plan. I talk with the attending doctor and consulted doctor about the wound if I have concerns, or simply state that I think the care is appropriate. I would never write anything derogatory in the chart. If that particular physician is not approachable, then I will write, "Consult appreciated, please consult if assistance is needed with ....." 
 
As far as the nursing home is concerned, you have two choices. Call a meeting with NH manager, the wound care specialist, and nursing supervisor. This would be an informative meeting just to let them know who you are, what you love to do and are successful at treating. Set the tone early stating you would love to work "with" not "exclusively." Leave it at that. If the consults come, they do; if they don't, then your proof will have to be in the pudding. Option two is not to treat at that nursing home. Bullying rarely works. It's more about the educational process than anything else. 

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Children's Heels from Hell

These shoes have not received the APMA Seal of Acceptance

Source: Submitted by Kathy L. Balderson, Associate Director Scientific Affairs, APMA who notes, "As a point of clarification, the Seal of Approval recognizes pharmaceutical products, FDA-regulated medical devices, and therapeutic (medicinal OTC) agents and the Seal of Acceptance recognizes footwear, hosiery, insoles, materials, and equipment. 

PRACTICE FOR SALE - ALABAMA, GULF COAST

Established 26 year old practice. Owner desires to sell and relocate. Operated 25 hours per week. Mixture of surgery and general podiatry. MD referrals. Surgery center and hospitals in close proximity. Highly profitable. Priced to sell.  Will lease office to buyer. Call Mike Crosby at 888-776-2430 or email mcrosby@providerresources.com

ASSOCIATE POSITION – MARYLAND

Maryland Eastern Shore Practice has opening for associate with ownership interest. MCR approved ASC, EMR, Ultrasound, Flouro, with Hospital Privileges available. E-mail CV to: patimmons@comcast.net  

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

CASE CONSULTING

Dennis Shavelson, DPM is accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds, pigmented & derm lesions, PRP and diagnostic dilemma’s from DPM’S. Full reporting with second opinion only and rapid return after care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

ASSOCIATE POSITION AVAILABLE-MIDTOWN MANHATTAN 
 
Looking for Full-time associate to work in well established practices in midtown Manhattan and Forest Hills. Immediate opening for PSR 24-36 surgically trained Podiatrist. Great opportunity with competitive salary along with malpractice benefits. Position includes Saturday office hours. Please send CV to slurie@papapc.net

PRACTICE FOR SALE – NEW YORK CITY

NY Manhattan, prime location. Upper East Side, 23. Y.O. practice, high visibility-traffic area next to post office, street level, All phases of Podiatry, NO surgery, retiring due to disability. call 516-759-4062 or Paulfxfeet@aol.com

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.

SALES REPRESENTATIVES WANTED

SureFit has immediate openings for three sales representatives – one for Midwest, Mid-Atlantic and Southeast territories. Responsibilities include but are not limited to obtaining new business, executing sales strategy, initiating contact with customers, identifying their needs and selling appropriate products to meet those needs. Ideal candidate will be enthusiastic, highly motivated individual with a positive attitude who prefers a team environment. Minimum requirements include Bachelor’s degree, 3+ yrs sales experience, preferably in Podiatry and/or O&P Industries. Position requires up to 70% travel with residency in each territory. Please e-mail resume and references to: James R. Grady, Director of Sales SureFit jgrady@surefitlab.com

OFFICE SPACE/ MRI RENTAL – NYC, LI   
 
Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, Hicksville and/or 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

PM News Classified Ads Reach over 11,500 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 11,500 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 Ext 110.

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