The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

July 25, 2009 #3,605 Publisher-Barry Block, DPM, JD

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APMA President Stresses Importance of Proper Children's Footwear

As parents and children begin their annual routine of back-to-school shopping, one item is a must-purchase for every list - shoes that fit properly. That's the advice from podiatrists who say that many adult foot ailments have their origins in childhood and are present at birth.

Dr. Ronald Jensen

"Neglecting foot health invites a host of problems and can leave children eligible to injury," said Dr. Ronald Jensen, president of the American Podiatric Medical Association (APMA). "It is highly important that parents purchase children's footwear that offers the proper support and fit necessary to keep a child's feet safe both at school and at home."

Source: Health News Digest [7/23/09

Wilson Appointed to WA State Podiatry Board

Gov. Chris Gregoire today announced the appointment of Suzanne Wilson of Seattle  to a term on the Washington State Board of Podiatry. Wilson is self-employed as a podiatric physician and surgeon. She is a member of the Washington State Podiatric Medical Association, American Podiatric Medical Association, American College of Foot and Ankle Surgeons, and American Board of Podiatric Surgeons.

Dr. Suzanne Wilson

The board examines candidates for licensure or registration, investigates charges of malpractice, unsafe conditions or unprofessional conduct, and conducts disciplinary hearings. The board also recommends and adopts rules and regulations to promote safety, protection, and welfare of the public.

Source: State of Washington [7/23/09]

Reform Legislation Deadline Pushed Back in Senate

Not 24 hours after the president went on national television to quell growing criticism over his effort to reshape the U.S. healthcare system, Senate Majority Leader Harry Reid (D-NV) officially unchained a key Senate committee from a White House-backed deadline. Reid said that the Senate would not vote on a comprehensive health reform bill before its August recess. The Senate officially goes on break Aug. 7, returning in September. The top senator said, “The decision was made to give them more time for the Finance Committee part of what we are trying to do, and I don't think it is unreasonable.”

President Barack Obama has said that he wanted a bill before the recess, but shrugged off the delay. “That's OK, I just want people to keep on working,” Obama told a town hall meeting in Cleveland, according to the Associated Press. “I want it done by the end of the year. I want it done by the fall.”

Source: Matthew DoBias, Modern Healthcare [7/23/09]

Query: Swimmer with Cramps in Arches

I have a patient who is a highly competitive swimmer who has been complaining of cramping in the arch of his feet when he is swimming and pointing his toes when kicking. This has been going on for the past 3 years. He does state it can happen at night as well but not as often. He need to relieve the problem by dorsiflexing his feet. He is not excessively tall, has a size 10 foot and is flexible with some IT band issues. No equinus is noted. No pes planovalgus deformity. He has been taking calcium/magnesium and has had some massage therapy. Any input is welcomed.

Alan Mauser, DPM, Louisville, KY

Query: X-Ray Processor

I need to purchase a new x-ray processor. Does anyone have any pros/cons regarding the AFP Mini-Med 90 Film Processor or Konica/Minolta tabletop model for a small one-doctor practice? Any feedback would be appreciated.

D.J. Loiselle, DPM, Largo, FL

Query: Billing CPT 97035

Does anybody have any experience with billing CPT 97035 (application of a modality to one or more areas; ultrasound, each 15 minutes)?

The representative at WPS Medicare said she couldn't tell if there would be a problem with provider type until we tried to send it through. Can a podiatrist bill CPT 97035 or is it restricted to therapists?

Jim Licandro, DPM, Bettendorf, IA

Response: The Medicare carrier's manual allows for reimbursement of procedures subject to the state license of the provider. I would think it would be discriminatory for a Medicare carrier to single out a specialty type and prevent them, based on their specialty, from performing any services or procedures when those are permitted under state license.

Therapeutic ultrasound (CPT 97035) is covered under "Physical Medicine and Rehabilitation (L26688)," and can be found on the WPS website. Here it spells out the guidelines, including frequency and diagnostic parameters under which you may be reimbursed for all physical medicine modalities. Podiatrists, like MD/DOs and physical therapists, would be subject to these guidelines.

Paul Kesselman, DPM, Woodside, NY

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RE:  Brachymetatarsia Surgery (Dale Shrum, DPM)
From: Multiple Respondents

To prevent deviation of the distal metatarsal after coracotomy, a K-wire should be driven across the MPJ to allow a track for the metatarsal to lengthen along. Additionally, the surgeon should place another carriage with bone pin in the base of the proximal phalanx, so that the MPJ can be distracted. Doing this during the lengthening will prevent post-op MPJ stiffness, which otherwise, would  cause your patient to complain about after frame removal.

Rick Wittock, DPM, St. Louis, MO, wittockr@sbcglobal.net

The 4th metatarsal does not appear to be distracted in the appropriate plane.  The distal fragment seems to be tracking more medially than would be optimal. Additionally, the use of a k-wire traversing the 4th MTP joint is mandatory with callus distraction to guide metatarsal lengthening and avoid MTP subluxation. 
 
In light of this, I would consider revisional placement of the fixator and pinning of the digit across the MTP joint.
 
Daniel J. Tucker, DPM, Orange, CA, ReekaT@aol.com

The quality of the images shown are not great, however, it appears that the proximal pin in the distal 1/2 of the metatarsal may not be in the metatarsal. In that case, you only have one point of fixation on that portion of the metatarsal. That allows the metatarsal to swivel on the remaining distal pin.

Better images, especially medial oblique views at different angles, should be able to confirm this.

Kenneth Meisler, DPM, New York, NY, kenmeisler@aol.com

RE: Chronic Sub-Hallux Ulcer in Diabetic (Marc Greenberg, DPM)
From: Multiple Respondents

You can either do an arthroplasty of the great toe IP joint (and take out the interphalangeal sesamoid, if present) or a Keller.

Philbert Kuo, DPM, Chesapeake, VA, philbear@pol.net

Dr. Greenberg, I rarely meet a compliant diabetic patient. These patients require you to be creative. A total contact cast was an excellent strategy, but it may have fallen short of the goal, off-loading the wound area. In my office, when we find the TCC is not effective, we look at the reason why. In your patent's situation, I would put tube foam around the toe (if possible), then place padding under the base of the toe that will not touch the wound area, and at the same time prevent the wound to feel pressure/friction. In my office, we will open up about five 4X4's and loosely ball them up under the forefoot, but not to extend under the wound area. Build the TCC to prevent the patient from putting any pressure or friction on the wound area-it is do-able.
 
Side note, if possible, shortening the flexor tendon at the wound site will plantar-flex the distal phalanx fat pad and prevent re-occurrence of the wound (usually/hopefully).
 
I find no matter how good my mousetrap, there is always a smarter mouse. Common sense, knowledge, compassion and creativity are the foundation of a good wound care physician. I admire your desire to avoid amputation.

Wm. Barry Turner, DPM, Royston, GA, claret32853@gmail.com

I have had a few patients with similar problems. I first try to load the 1st met and see if they have a functional hallux limtus. Almost all do. I explain it like this: Your foot is trying to bend at the ball of the foot, but because of the mechanics, it is putting stress at this joint (pointing to the IPJ and the ulcer area), causing extra pressure and friction. I then recommend a Keller arthroplasty (taking a fair size wedge from the base of the PP). It seems to take care of the problem the majority of the time.

John Keenan, DPM, Lehighton, PA, jkeenan@aol.com

RE: Warts in an HIV Patient (Tip Sullivan, DPM)
From: Geoffrey Bricker, DPM, Jeffrey Kass, DPM

I use Lazerformalyde for most warts unless they are well circumscribed and deep. Debride monthly and apply silver nitrate; then have the patient apply the formaldehyde 2-7 times per week, enough to keep the area dried out. Warts usually resolve in 4-6 months. Recalcitrant lesions can then be excochleated and cauterized with a low chance of recurrence.

Geoffrey Bricker, DPM, Springfield, MO, geoffreybricker1@msn.com

I usually reserve surgical excision of warts as a last resort. If the lesions are under weight-bearing regions - there is a possibility of a painful scar. For plantar surface versus dorsal surface, I have had more success with Effudex than Aldara. I have the patient apply it under occlusion with duct tape BID.

In recent weeks, there has been mention on this forum of the Cryoprobe unit which is another option. While, I lost access to a pulse-dye laser, I found it to be highly effective at treating the most recalcitrant warts.  
 
Jeffrey Kass, DPM, Forest Hills, NY Jeffckass@aol.com

RE: Planning for the Future (Name Withheld)
From: George F. Jacobson,  DPM

In 1987, after being in practice for 2 years, with the family growing, it was time to protect them from a potential catastrophic injury or illness. I purchased life insurance with a disability waiver. I also purchased the disability policies with personal funds over the next 3 years as my income improved. Lastly, I purchased an overhead policy to keep the practice running for one year (it was available for two years). It would pay overhead expenses for 12 months. 

In 1992, at 36 years old, I had two enlarged lymph nodes (RT neck and axilla). A biopsy was performed and it came back metastatic malignant melanoma from an unknown primary source (10% 1-year survival rate).  My kids were 10, 6, and 2. 
 
I did estate planning with an account and attorney. Because I paid the disability policy with private funds, the monthly payment was not taxed as income. The disability waiver pays the premium for the life insurance. The overhead policy turned out to be very important, especially as a solo practitioner, while trying to find a replacement doctor. After the diagnosis, I took out the Florida Prepaid Tuition plan to pay for college for all three kids. The sooner you do this (if your state has a similar plan), the lower the payments.   
 
Don't forget health insurance as part of your planning. It will not be easy to change policies once you have been diagnosed. One can take out disability and life insurance to buy out a partner should a catastrophe arise.  Use an accountant for estate and business planning, then formalize the plan with an attorney. Once your life is threatened, it's too late.
 
George F. Jacobson, DPM, Hollywood, FL, fl1sun@msn.com

RE: Heels From a Watery Hell

These shoes do not have the APMA Seal of Acceptance

Source: Submitted by Edwin Bruno, DPM, Bangor, ME 

PRACTICE OPPORTUNITY - CINCINNATI, OH
 
Well-established practice located in medical/professional building minutes from hospital. Many referrals, three satellite clinics and two assisted living facilities to keep you busy. Associate leaving due to family emergency-need to either find an associate or sell ASAP. Contact bjadpm@hotmail.com for more details.

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

ASSOCIATE POSITION – ILLINOIS 
 
Quality Podiatry Group provides quality services to residents at long term care facilities. We are currently offering full-time or part-time positions for motivated ethical podiatrists. Immediate openings available. If interested, fax curriculum vitae to 312 225-9366 or e-mail feetwork@aol.com

ASSOCIATE POSITION - BOSTON, MA 
 
Associate wanted, Full-time or part-time, for busy long time, well established, and well-rounded practice. Good mix of general podiatry and surgery. Office will generate approximately 100+ surgical cases per year. Must have surgical background, ABPS Qualified minimum needed to obtain hospital privileges. Associate position is open for partnership or purchase. Contact robert.nunberg@comcast.net 

ASSOCIATE POSITIONS - CALIFORNIA

Podiatrist needed for busy North Hollywood office. Part-time Monday-Friday 8am-2:30pm. No weekends and no call. Pay negotiable. New podiatrists are encouraged to apply. Please email resume and salary request to Coasttocoastpodiatry@yahoo.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.

ASSOCIATE POSITION – PACIFIC NORTHWEST

Russian-speaking podiatrist needed. Looking for well-rounded, recently out of residency, podiatrist. Would you like to raise your family in our beautiful Pacific Northwest? We are well-established and fast growing multi-office practice with all aspects of podiatry. Attractive compensation, malpractice and medical insurance provided. Contact Dr. Ilona Barlam at 206-661-9644.

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

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 fmassuda@footexperts.com

PRACTICE FOR SALE – WESTCHESTER COUNTY, NY

Established 30+ year old practice. Well respected podiatrist in beautiful Westchester County Owner ill and needs a quick sale. Mixture of surgery and general podiatry. Hospitals in close proximity. Will lease office to buyer. Call Mali McGrinder at 914-434-1663.

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