The Voice of Podiatrists

Serving Over 9,800 Podiatrists Daily

September 03, 2007 #3,030 Editor-Barry Block, DPM, JD

A service of Podiatry Management http://www.podiatrym.com
E-mail us by hitting the reply key.
COPYRIGHT 2007- No part of PM News can be reproduced without the
express written permission of Kane Communications, Inc.

TX DPM Receives Young Investigators Award

Jayme Williams, DPM received the Young Investigators Award for her oral Presentation: “Anodyne Therapy: Fact or Fiction” at the 2007 Symposium on Advanced Wound Care in Tampa, Florida

Dr. Jayme Williams

Dr. Williams is one of Dr. Lawrence Lavery's Research Fellows at the Texas A&M Health Science Center, Scott & White Memorial Hospital in Temple, TX. Dr. Lavery's program equips young professionals in all aspects of research design and publication.

TX Podiatrist Dispels Myth About Walking on Broken Foot

Old wives' tales and myths are fun to laugh at. We believed them growing up. "Step on a crack and you'll break your mother's back.” But there are other myths that are no laughing matter, especially when they involve your health. From bunions to broken toes, doctors with the 6,000-member American College of Foot and Ankle Surgeons (ACFAS) have heard it all.

Dr. Samuel Nava

Myth: My foot or ankle can't be broken if I can walk on it.
Reality: It's entirely possible to walk on a foot or ankle with a broken bone. "It depends on your threshold for pain,” as well as the severity of the injury, according to Samuel Nava, DPM, FACFAS, a Dallas-based spokesman for the College. But it's not a smart idea. Walking with a broken bone can cause further damage.

It is crucial to stay off an injured foot until diagnosis by a foot and ankle surgeon. Until then, apply ice, and elevate the foot to reduce pain.

NYSPMA Provides Back-to-School Shoe Buying Advice

If the shoe does not fit, it is time to get a fresh pair for the new school year, according to Dr. Robert Rampino, President of the New York State Podiatric Medical Association (NYSPMA).

Dr. Robert Rampino

With the belief that ill-fitting shoes become a prescription for academic failure, NYPSMA offered to join together with parents to help select the proper shoes for their kids before the school season. “Kids always want what looks good, not necessarily what fits best,” Rampino said.

To counteract foot problems that originate with poorly fitting shoes, finding the correct size and purchasing a larger fit is essential. In addition, shoes should never be bought based upon their numerical size, for the fit varies among different brands and styles. “What’s more, few shoe stores have sales professionals properly trained to measure and fit shoes,” said Rampino.

Source: Natalie Shields, Queens Courier [8/30/07]

Query: Uncontrolled Gout

I have a 60 y/o female patient who has severe gout in her feet. She is allergic to every anti-inflammatory medicine except cortisone. We have tried OTC products such as cherry extract; again with no relief. She continues to develop numerous gouty tophi that we have to remove surgically, along with the repeated and persistent gout attacks.

We have consulted with two rheumatologists who have all but given up, and have left her on Enbrel. Does anyone have a solution to help dissolve some of the gout crystals, either by injection or orally.

Randy Lisch, DPM, Austin, TX

RE: Requirements for a Podiatrist to Serve as a Coroner (Scott Hughes, DPM)
From: Joseph Campbell, DPM, Joel Gluck, DPM

The answer depends on your respective state law. It also depends on the type of local govt that you reside under. In PA, the coroners are elected like any other county row office (e.g., Commissioners, Sheriff, Controller, Treasurer, Clerk of Courts, Register of Wills, etc) all of which serve 4-year terms. Getting elected requires lots of work and a passion for politics before one can perform the job of investigating a death.

Fact: Less than 25% of the coroners in PA are physicians, most are funeral directors, retired police, nurses, or have EMS backgrounds. We all use forensic pathologists to do our autopsies. The size and nature of each county's coroner’s office is reflective of the respective population of that county. Please note real world forensic/death scene investigation is far from what you see on CSI/TV.........

Joseph Campbell, DPM, Coroner Bucks County, PA, jcqtn@nni.com

The requirements for being a coroner are not the same as a medical examiner. In fact, most towns that have coroners employ funeral directors. Coroners investigate deaths, mostly unusual ones. This does not require an MD/DO.

Joel Gluck, DPM, Warwick, RI, JGluc1@aol.com

RE: High Cost of Malpractice (John Levin, DPM)
From Multiple Respondents

What Dr. Levin calls attention to should raise all of our eyebrows. He gives an example of where an "expert" called in by the plaintiff had very little evidence to support his position that his colleague did wrong. Yet the court allowed the plaintiff to base his case on it. This might have been acceptable in the past, but today we live in the era of evidence-based medicine. We are taught at conferences and in the medical literature that we should not prescribe medications or perform surgical procedures unless these treatments are supported by adequate medical research. Yet the court system in many cases still uses an antiquated system where a jury bases its decision on one man’s opinion, and as in the case cited by Dr. Levin, an opinion is just that: one person's opinion that is often devoid of facts. It’s time that the medical profession redirect its aim and some of its anger from crooked "experts" and petition the courts to hold the same evidence-based standards that we as physicians are held to. This in essence would kill two birds with one stone.

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

After reading several replies to a posting regarding the cost of malpractice, I was sorry to read about the experiences that some podiatrists have had as a result of unscrupulous practitioners serving as plaintiff’s witnesses. While I don’t know whether or not their claims are true, it is shocking to me that someone who repeatedly makes questionable decisions and statements would be allowed to keep their license to practice. As a second year resident, I am a bit naïve on this subject, but isn’t there some sort of legal recourse against podiatrists (or any other practitioner) who clearly makes inaccurate judgments or statements for profit?

Eric Hart, DPM, Salt Lake City , UT, ericandalix@yahoo.com

I would like the PM readers to consider the following with regard to those who offer outrageous testimony inconsistent with podiatric/medical fact. Prepare a detailed case and petition the PA State Board of Podiatry (or wherever), ABPS, ACFAS to consider ethical violations with subsequent sanctions or admonitions. Prepare a detailed and proper complaint with the assistance of a lawyer. Provide appropriate references.

If the testimony is that egregious and outrageous, demand a review for ethical violations. No one is suggesting that you cannot provide testimony in support of a plaintiff; however, such testimony must be truthful. Once the "experts" such as Drs. Gorman, Boc, etc. are cited for the failure to provide truthful testimony, they will be finished as experts, as every subsequent deposition and courtroom testimony will include a history of being cited for untruthful testimony. In addition, there is always the possibility of loss of ACFAS fellowship status or better yet, ABPS diplomate status for unethical behavior. Even a letter of condemnation or warning from such organizations would provide the jury with a true picture of the "expert."

One other matter: If a college protects a full-time plaintiff paid confabulator, let the college know that you will not support the organization.

Allen Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net

RE: Predislocation Syndrome (Michele Parker, DPM)
From: Multiple Respondents

The etiology of this particular PDS would appear to be the HAV deformity. I have had no success without correcting the underlying etiology. Injections should be avoided because they seem to only potentiate the dislocation.

Thomas A. Brosky II DPM, Atlanta, GA, dr.brosky@charter.net

In regards to patients with pre-dislocation syndrome demanding conservative treatment, I have had some moderate success with the use of clogs with a rigid forefoot rocker or an orthotic with a second MPJ dispersion pad and a large metatarsal pad placed proximal to it to elevate the metatarsal and reduce the hammertoe a little(if semi-flexible). It helps off-weight the area and is usually at least temporarily effective. Surgery is the best option- get an MRI and see if the plantar plate is torn. If it is then you may better be able to convince the patient that surgery is necessary.

Chris Ferguson, DPM, New York, NY, cfergdpm@yahoo.com

I don't think a steroid injection of any kind will do this patient any service in the long run. The deformity is unchanged, so the pain will likely return. If a patient understands this and is willing to get an injection, then I would consider injecting only one time. You don't want to do more damage to the joint than it already has. 1/4 - 1/2 ml of Kenalog should be more than enough to get the job done. Perhaps a return of the pain will convince your patient that surgery is a reasonable option, but beware of "forcing surgery". Consider an accommodative orthotic in the list of conservative options as well. Another consideration in the patient who has failed conservative treatment and would benefit from the surgery they are afraid of, for whatever reason, is a second opinion. Don't be afraid to enlist the help of your peers!

Marc Greenberg, DPM, Dayton, OH, tripperdpm@yahoo.com

Many respondents argue against steroid injections. Many of our colleagues use steroids with excellent results. Many recent studies dispel the notion that these injections weaken connective tissue. Spontaneous rupture of the plantar plate/joint capsule seems to occur just as frequently without the use of steroids. Regardless of one’s position, I would recommend that we not condemn a a treatment commonly used by our colleagues. This instigates litigation and leads a physician to worry more about litigation that healing the patient.

Matthew Roberts, DPM, Miami, OK, matrob@pol.net

"Forcing surgery?!" The patient shows great wisdom refusing second digit arthrodesis, plantar plate surgical treatment and a first metatarsal osteotomy especially when there is no mention of the use of foot orthoses. In my experience, the combination of custom foot
orthoses along with the other mentioned conservative care modalities heals 90% of these injuries. Without prescription foot orthoses, the success rate is probably less than 50%. As follows are the standard modifications to the custom foot orthoses I most commonly use for 2nd metatarsophalangeal joint capsulitis/plantar plate tears:

1. Neutral suspension casting
2. Balance positive cast 2-5 degrees inverted with 2-3 mm medial heel skive.
3. Use 3/16" polypropylene with 4 degree/4 degree rearfoot post.
4. Make orthosis anterior edge shape to match parabola of each metatarsal neck (i.e., orthosis will be longest at 2nd metatarsal neck)
5. Make anterior edge of orthosis 3/16 thick with abrupt drop off (i.e., "internal metatarsal bar effect")
6. Use full length neoprene topcover with forefoot extension of 1/8" Korex to sulcus plantar to metatarsal heads 1, 3, 4 and 5 to accommodate 2nd metatarsal head.

By the way, why is foot surgery being offered before foot orthoses are even attempted? Would you offer a plantar fasciotomy before trying foot orthoses for plantar fasciitis? Patients deserve premium conservative care for their foot injuries from their podiatrist, not just a half-hearted attempt at conservative care before the foot surgeon "forces" the patient into a "definitive surgery." We, as a medical profession, owe not only the best surgical care to our patients, but also the best conservative care!

Kevin A. Kirby, DPM, Sacramento, CA, kevinakirby@comcast.net

ASSOCIATE POSITION - NORTHWEST PENNSYLVANIA

Multi-specialty group is looking to add another Podiatric Surgeon or General Podiatrist to our well-established group. Office locations in northwestern Pennsylvania. Unlimited opportunities exist for the right Associate, wound care experience is a plus. Please forward your CV to adminsec@ips-mso.com

CRYOPROBE SALE: ADDITIONAL PRICE REDUCTION!*

A cryoprobe system (less than one year old and rarely used) from CryoTech is available for only $9750.00 or *best offer*. This lists for $14,900.00 new. The CryoPac system comes complete with two fully sterilizable Probes. This system has been used less than 15 times and can be used to treat plantar fascitis, neuromas, and other foot pathology. Please email inquires or your offer to: drsammendicino@gtef.org

SATELLITE PODIATRY OFFICE FOR RENT - TUCSON, ARIZONA

Modern x-ray with automatic processor. Professional atmosphere. office is shared space in a chiropractic office with separate front desk. Excellent start-up opportunity for a new doctor Front desk staff, copy machine, fax are also available. Contact Dr. Parks at 520-544-2445 or parksovc@aol.com

INDEPENDENT CONTRACTOR WANTED - KANSAS CITY, MO

Immediate opening for podiatrist as independent contractor. Flexible schedule. All phases of podiatry. Knowledgeable and dedicated support staff. Must be compassionate and personable physician with good podiatric skills. Wonderful place to live and work. Please email CV and letter of interest to: Dr.Fine@FineFootCareCenter.com

• To Post a message, send it to:    bblock@podiatrym.com
• Notes should be original and may not be submitted to other publications or listservs without our express written permission.
• Notes must be in the following form:
  RE: (Topic)
  From: (your name, DPM)
  Body of letter. Be concise. Limit to 250 words or less). Use Spellchecker
  Your name, DPM City/State
• Subscribers are reminded that they have an ethical obligation to disclose any potential conflicts of interest when commenting on any product, procedure, or service.