The Voice of Podiatrists

Serving Over 9,800 Podiatrists Daily

October 12, 2007 #3,064 Editor-Barry Block, DPM, JD

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Foot Pain Can Be Sign of Vascular Problems: NY Podiatrist

Foot pain can mean a lot more than the usual aches from a long walk or standing on the feet all day. Some foot pains, particularly those that persist for more than a couple of days or even weeks, can be early signs of vascular disease, diabetes or even cancer and should not be overlooked, according to podiatrists.

Dr. Jennifer Fung-Schwartz

Dr. Jennifer Fung-Schwartz, podiatrist at the Cabrini Medical Center in New York and spokeswoman for the American Podiatric Medical Association (APMA), said that retailers or other people who may spend all day on their feet at work will usually have foot pain because the muscles may be worn or they may not be getting the right support in their footwear. But the pain should not be taken for granted and should be checked by a doctor, especially if it persists, because it could be something serious, she said.

Vascular problems may make it painful for some to walk due to a blockage that prevents the blood from making it to the muscles. Fung-Schwartz said that if not treated (more potassium in the diet can help), this can lead to amputation because of poor circulation. “You have to ask the patient when it is happening,” she said. “They will tell you at night ‘my legs will hurt when I’m in bed.’ If they tell you that, there may be segmental pressure, which measures the pressure in lower extremity starting from upper side all the way down.”

Source: Tina Benitez, Fox News [10/9/07]

TX Podiatrist, a Former Circus Performer, Wins Harry Potter Contest

Dr. Debra Lusk's is one of the winners of a Scholastic sweepstakes, and gets to hear Harry Potter author J.K. Rowling read part of "Harry Potter and the Deathly Hallows." She also gets an autographed copy of the book and to have a short Q&A with the author in New York City's Carnegie Hall on Oct. 19th.

Dr. Debra Lusk (Photo Tammy McKinley)

In the late 70's, Dr. Lusk, a petite woman with auburn hair, had spent two years with the Ringling Brothers Circus and rode on the elephants. She was working in Houston at the time, wanted to travel, saw an ad for auditions and thought "I can do that." She tried out, got the job and spent the next two years performing in sequined costumes with elephants.

She had wanted a career in medicine and during a break in Salt Lake City, went to a nearby health fair and saw information on what careers would be needed in about 10 years. Again, she thought, "I can do that." One of the following stops was Chicago, where she picked up an application to podiatry school. That's where she went to school, met her husband and her partner in the podiatrist practice, who was from Beaumont.

Source: Christine Rappleye, Beaumont Enterprise (TX) [10/10/07]

Researchers at UCLA Find New Blood Test to Predict Type 2 Diabetes

Type 2 diabetes is caused by poor eating habits, hereditary, and lack of exercise. But now, researchers at UCLA say there is another risk factor that doesn't have to do with weight, diet and genes that can help predict who's likely to develop diabetes.

"Some of these markers can actually be measured fairly consistently and reliably long before the disease occurs," said Dr. Simin Liu, epidemiology professor at UCLA. They're called inflammatory cytokines, proteins made by our fat tissue. It's when you have too many of them that they become a risk.

"Obese people tend to have elevated levels of these kinds of cytokines," said Liu. But thinner people can have them too. A simple blood test can tell you if you're on the road to diabetes. Liu hopes his research leads to a drug that can lower cytokine levels, but even without medication. "You can lower your body weight via exercise and dietary changes - and those are well established regiments you can adopt to lower risk of diabetes," said Liu. If people knew they were going to get diabetes, would they take precautions? This new test may help future generations. Some labs can test blood for elevated levels of cytokines.

Source: Diabetes in Control Newsletter [10/9/07]

Query: Transdermal Verapamil 15% Gel for Plantar Fibromatosis

I would like to hear the experiences of anyone who has used Verapamil 15% Gel transdermal patches for the treatment of plantar fibromatosis.

Kenneth E. Jacoby, DPM, Elgin, IL

RE: Painful Hallux IPJ Lesions in Diabetic (Michael J. Ryan , DPM)
From: Multiple Respondents

This sounds like a classic case of functional hallux limitus. The hallux cannot dorsi-flex on the met head during gait, so pressure builds under it. Try using a 1st met head cutout to his current shoe insert. Should not negatively impact his hips or lower back (it may actually improve them) and should over time, alleviate the sub hallux pressure and breakdown.

As an aside, this type of case is ideal for in-shoe pressure analysis like F-scan to determine what type of change (and the amount) is required to reduce sub hallux pressure.

Howard J. Dananberg, DPM, Bedford, NH, howiedbpg@aol.com

If he's pronating excessively (which is why he has these lesions in the first place), a basic functional orthotic with perhaps a soft tissue supplement cover should make a big difference. Even if you did some surgical procedure, you'd want him to have orthotic control, so why not do it first?

Paul Busman DPM,RN Cohoes, NY, BREWERPAUL@aol.com

We have had some success having our pedorthist attach a metatarsal bar to the sole of the shoe just proximal to the metatarsal heads. A metatarsal bar is easier to tolerate than a rocker bottom insert and does a good job in most patients in off-loading the forefoot in stance. It is also very easy and cheap to apply. It also helps negate the effect of a tight Achilles on forefoot pressures. All this is clinical observation, not research.

Juliet Burk, DPM Tahlequah, OK, julietburk@gmail.com

Hopefully the pedorthist you referred this patient to has contacted you with a suggestion such as this. The patient should be fit to an orthoses with a depression beneath the hallux to allow the lesser digits to bear increased weight which decreases the pressure on the ulcerations. A low shear topcover should be utilized, or a product such as Shear-ban positioned in this area. More importantly, directional rigid rockers should be employed. By directional I mean that the apex of the rocker should be ground in such a fashion as to remain perpendicular to the line of progression, not the longitudinal midline of the shoe. This will reduce the amount of pressure and duration of time spent on the forefoot during gait while not attempting to rotate the limb. This should protect the patient’s knees, hips and back.

Christopher Costantini, C.Ped., Rochester NY, cjcped33@yahoo.com

RE: Podiatric Biomechanics: Was Schuster Right After All? (Jeff Root)
From: Robert Scott Steinberg, DPM

I have said, on many occasions, that we, as podiatrists, need to set the standard in the use of functional foot orthoses. I have also stated that anything less then plaster casting is cheating the patient because I do not believe foam boxes or computer scans can produce a actual functional foot orthotic.

I do not order arch fill, though I suspect labs sometimes add some, especially if they suspect the cast was not taken properly. All of this I do because I believe Merton Root, DPM got it right.

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

RE: Mac-Based Podiatric Billing Software
From: Gregory Markantone, DPM (Len Sanchez, DPM)

I too was a soft easy user (Mac-Based program). I have switched to DBC and have never regretted the move. The program, training and support have been great. I have been a DBC user for 8 years now. Feel free to contact me. I would be glad to give you further insight into the program.

Gregory Markantone, DPM, Latrobe, PA, gmarkantone@wpa.net

RE: Telephone Inquiry for Nail Care (Ken Malkin, DPM)
From: Multiple Respondents

Dr. Malkin asks how staff is trained to handle the following phone caller: “I want to make an appointment to have my nails cut. I have Medicare and XYZ as a secondary. Will I have to pay anything?” Over the years, few inquiries are able to raise my blood pressure more. Sometimes variants of the question are posed actually when the patient arrives in the office for the first time. On the issue of “Will I have to pay anything?” we have no one but ourselves to blame. There is always someone in every community who thrives because no one ever has to pay anything. You can interpret that as you wish. The issue of explaining Medicare coverage guidelines is another nightmare, ongoing for 30 years now, with our profession and all its advances standing completely impotent to solve it.

About ten years ago, my practice administrator pointed out to me that encouraging these visits, guidelines met or not, is economic suicide. For that reason, patients referred from physicians sent for this purpose only are seen for the first visit, which is always covered. The patient is then discouraged in any number of diplomatic ways from seeing me again for nail care, covered or not. When a patient calls with that question and is not physician referred, my practice manager asks them if there is any pain or possible infection. If the answer is no, she is instructed to refer to other podiatrists in the community with whom I have pre-arranged the possibility that I would be sending such patients, and who accept all of the inherent limitations.

Bryan Markinson, DPM, New York, NY, Bryan.Markinson@mountsinai.org

We tell the patient that the first visit will be covered and at the initial visit, the doctor will determine whether or not subsequent visits for "foot care" will be covered by their carrier.

Lisa Schulze, San Antonio, TX, lisa.schulze@yahoo.com

In our office the assistants have been trained to say the following --"Until your condition is diagnosed as being reimbursable under Medicare guidelines we cannot answer this question. Also, your Medicare benefits must be certified. As far as the 20% co-insurance, you may be responsible for this portion. If you would like to make an appointment we will be pleased to see you and take care of your nails, put you may be responsible for the full fee."

Janet Grace, PMAC, Schiller Park, IL Janetgpmac@aol.com

The staff says "Medicare has very specific guidelines for nail and callus care. You have to meet certain criteria which have to do with poor circulation or diabetes. The doctor will examine your feet and will let you know if you qualify for Medicare coverage for routine foot care."

Jennifer B. Ryder, DPM, Rapid City, SD, jenbenryder@yahoo.com

Editor’s Note: This topic is now closed.

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