The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

October 29, 2009 #3,687 Publisher-Barry Block, DPM, JD

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TX Podiatrist Warns Recreational Runners Against Overtraining

Almost 40 percent of this year's runners at the New York Marathon will be first-timers, and Dr. Jeffrey Ross, a podiatrist who has run 25 marathons over 30 years, says they have at least one edge. "They haven't been beaten up yet," said Ross, himself sidelined by injuries this year. "I've run London, Jerusalem, Boston, but I still love New York the most," he said. "When you cross the 59th Street Bridge there's this huge crowd. Women in fur coats cheer you on." 

Dr. Jeffrey Ross

Ross warns recreational runners against overtraining. "Twenty miles a week is about right." He said recent running-related deaths during marathons in California and Michigan underscore the need for medical check-ups. "People need to see a primary care physician, a foot specialist, and probably get a stress test. More if there's a family history," he said.

Ross said the last six miles or so is where "push comes to shove" in marathon running, and there's no crime in waiting a minute at each water stop, or walking. "George Sheehan said he didn't mind running in the back of the pack as he got older," said Ross, referring to the runner and author of "Running and Being." "He was still in the pack."

Source: Dorene Internicola, Reuters [10/26/09]

PA Podiatrist Re-elected as PCA Board Chairman

Arthur E. Helfand, DPM, has been re-elected for a third term as Chairman of the Board of Directors of the Philadelphia Corporation of Aging (PCA) a non-profit agency established in 1973 to improve the quality of life for older Philadelphians. Helfand is Professor Emeritus at Temple University, Adjunct Professor of Medicine at the Temple University School of Medicine, and consultant to Temple University’s Institute on Aging.

Dr. Arthur E. Helfand

Helfand formerly served as professor and chair at the Department of Community Health, Aging, and Health Policy at the Temple University School of Podiatric Medicine. He is a former president of the American Podiatric Medical Association and a former chair of the Pennsylvania Diabetes Academy.

FL Podiatrist (and Husband) Open Healthy Eating Restaurant

At Cress, a new restaurant in downtown DeLand, the owners buy what local produce they can and grow much of the rest. Hari and Jenneffer Pulapaka, a Stetson University math professor and a podiatrist respectively, started the restaurant to promote a gourmet style of healthy eating emphasizing locally grown produce. While Cress can delight carnivores with Wagyu beef, bison short ribs or an egg roll of spicy venison, Pulapaka grew up in Mumbai as a vegetarian; his American-born wife has become one.

Dr. Jenneffer Pulapaka

Pulapaka’s imagination in vegetarian cooking is showcased in full-course tasting menus and cooking classes. “I appreciate dishes that are not just pasta primavera or curry,’’ says Pulapaka, who trained as a classical chef and is tired of those usual offerings to vegetarians. “It’s a misconception that it has to be boring.”

Source: Chris Sherman, Florida Trend [11/1/09] 

NY to Offer Price Comparison Website for Consumers

Using almost $100 million it received in settlement money from insurers, the state of New York created a not-for-profit company and an independent research network to develop a database and Web site that patients can use to compare prices for healthcare services, New York state Attorney General Andrew Cuomo announced.

The company is called Fair Health and the research network will be headquartered at Syracuse University, but will also include Cornell University, the State University of New York at Buffalo, SUNY Upstate Medical University and the University of Rochester. It will be led by Deborah Freund, a professor of public administration at Syracuse University.

Fair Health and the research network also will create a consumer Web site so patients can calculate how much they will be reimbursed for out-of-network healthcare services in their area, a news release said.

Source: Andis Robeznieks, Modern Healthcare [10/27/09]

Query: Transmetatarsal Amputation in a Sensate Patient

A healthy, 64-year-old female is requesting a transmetatarsal amputation. She has a history of a previous hallux fracture, 1st MPJ implant surgery with resultant complications and eventual amputation at the level of the 1st metatarsal neck from years ago. Her chief complaint is pain from contractures and medial deviation of the lesser MPJs due to years of not having a big toe.

This patient is requesting a transmetatarsal amputation.

She is not neuropathic, unlike all of the previous TMAs I have done. Are there any tips or pearls regarding avoiding stump neuromas and the like when performing this surgery on a sensate patient?
 
Jared Clifford, DPM, Prosser, WA
 

RE: Perceived Ingrown Toenail Problem (Hans Blaakman, DPM)
From: Todd Lamster, DPM, Elliot Udell, DPM

According to Dr. Blaakman’s description and the photo provided, it appears as though the surgery was a clinical success.  The symptoms of such severe pain (and maybe hypersensitivity?) make me think of a neurological origin for her pain. Do a thorough neuro exam and ask about other indicators of neuropathic pain. Ask about her other pains, possibly in her hands and back. Check for thyroid, diabetes, alcohol, and vitamin supplements. 

Todd Lamster, DPM, Phoenix, AZ, tlamster@gmail.com

The fact that the patient says that she had exquisite pain after the procedures, it took three months for the toes to heel, and she has had no relief in any of the toe nail borders treated, is suspicious. The fact that there is no recurrence of nail growth at any of the four borders as well as photos which depict very good results renders me even more suspicious. Many, if not most of us, have had phenol alcohol procedures which have had to be redone but rarely would four out of four fail; and there is nail regrowth, the presence of scar tissue, skin retraction or other causes which are readily observable. None are present in this case.

You should do a work-up which would include radiographs to rule out subungual exostoses and blood tests to rule out some of the sero-positive connective tissue disorders. Contacting the surgeon who did the original procedure to determine if the nails were incurvated in addition to causing pain might be helpful in the evaluation. After all is said and done, I would not be surprised if this turns out to be a case of malingering behavior. The motive might become apparent if down the road the patient initiates litigation against the surgeon or applies for some other form of compensation.
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Recommendations for Bunionectomy (Alan Berman, DPM )  
From: Multiple Respondents

Just from the DP view, one will tell that this is a very difficult case. Theoretically, one would need to address the IM angle, possibly a Logroscino or a Lapidus. Considering her age though, those are very aggressive procedures. I would also consider a 1st MPJ fusion. I don't believe addressing the PASA along with transpositional osteotomy will effect a lot of IM correction or do much for her HAV deformity even with a fibular sesamoidectomy. If you do, I would mitigate the patient's expectations of correction. 
 
Angelo Bigelli, DPM, North Providence, RI, toedocri@aol.com

From a deformity standpoint, I would not think of a distal osteotomy procedure. My choice would probably be a Lapidus combined with a Reverdin-Akin. BUT, this patient must understand that the next surgery is a "salvage" procedure and the amount of time necessary for her to reach her present activity level will be many months. This patient had surgery 20+ years ago, and with the exception of the aesthetics, is very happy. I didn't read that the patient is unable to wear normal footwear, or that there are any physical limitations experienced with her deformities. I have found that this is not the most appreciative type of patient if ANY issues develop. Make certain your explanations are thorough and she is aware of the planned procedures, is very clear on the post-operative course, and possible complications.
 
Barry A. Wertheimer, DPM, Redondo Beach, CA, bwertheimer@cox.net

I really think that doing anything which alters the current congruency of this joint is to ask for trouble. This joint has significant adaptation/degeneration and functions well despite this severe deviation. Dr. Berman states that this patient has no symptoms other than some nail border discomfort and participates in gym activities 5-6 days a week, I think that statement should guide his treatment. As someone who does a fair number of revision Lapidus procedures, I would advise that if, and I repeat, if she ever develops joint pain, I would advocate a well-positioned arthrodesis.

Glenn M. Weinraub, DPM, Danville, CA, gweinraub@aol.com

RE: Effect of Custom and Semi-Custom Orthoses on 2nd Metatarsal Bone Strain (Robert Bijack, DPM)
From: Kevin Kirby, DPM, Ed Davis, DPM

It is unfortunate that Dr. Bijack can’t see the scientific significance of the cadaver research study which was so expertly performed by Meardon, et al., and that was just published in the peer-reviewed Journal of Foot and Ankle International. Their research is very important for those of us who are interested in the biomechanics of the foot and lower extremity and who are actively seeking scientific research data that will allow us to make better treatment decisions for our patients.

In order to determine the actual bending deformations of bone that are thought to cause such painful and common conditions as metatarsal stress fractures, metatarsal stress reactions, tibial stress fractures, and medial tibial stress syndrome, bone strain gauges must be implanted directly onto a bone that is being subjected to weight-bearing forces. Currently, Sweden is the only country in the world that allows invasive studies involving the placement of bone pins or strain gauges on the bones or tendons within the body of living subjects. However, in all other countries, this type of direct measurement of bone deformation can only be done on cadaver specimens due to medical ethical considerations.

The dynamic gait replicator developed by Erin Ward, DPM, and the dynamic gait simulator, co-developed by Andrew Hamel and Neil Sharkey, PhD, at Penn State Biomechanics Lab, are the only two such cadaver walking simulators within North America. These devices allow the researcher to very closely approximate the mechanics of human walking, so that invasive dynamic gait studies can be performed on the human foot and lower extremities with no risk of infection or surgical pain. Both of these research centers have produced amazing scientific research data over the past decade that has allowed us to better understand both the kinetics and kinematics of the human foot.

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

Editor's note: An extended-length letter by Dr. Davis can be read at: http://www.podiatrym.com/letters2.cfm?id=30002&start=1

RE: Vascular Testing Systems (Tamara Allen, DPM)
From: Robert Wunderlich, DPM

Regarding Padnet+, the only concern I have about this system is that it does not use a Doppler probe to obtain segmental pressures. Instead, it uses a method called oscillometry. Though oscillometry may indeed be as accurate as a Doppler in obtaining segmental pressures, there is a potential issue with Medicare reimbursement. Specifically, my local carrier (Trailblazer) published the following in the relevant LCD (Non-Invasive Peripheral Arterial Studies – 4U-20AB-R2):

Under 'Reasons for Denial':

"•The following methods are not reimbursed under the HCPCS codes listed in this policy (i.e., 93922, 93923, 93924, 93925, 93926, 93930 and 93931): •Mechanical oscillometry.•Inductance plethysmography. •Capacitance plethysmography. •Photoelectric plethysmography. •Ankle/Brachial Indices (ABI) (considered part of the physical examination). "

So, I would recommend verifying with your local Medicare carrier whether the oscillometry used in Padnet+ is indeed reimburseable for CPT's 93922 and 93923. It also would be worthwhile to carefully review the entire LCD on this subject prior to billing Medicare for non-invasive arterial studies.

Robert Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com

RE: Ultrasonography Course (Marc Katz, DPM, Alan Kalker, DPM)
From: Asa Phillip Hager

Universal Ultrasound also has a Ultrasonography course in NY that is taught by John Cozzarelli, DPM and Joystna Thapar, DPM. The course is very informative and hands-on. If you are looking to learn how to visualize structure and pathology for the first time, or you are looking to refine your skills, this course is a must. It is offered 4 times a year and free to Universal Ultrasound customers.

They have a full line of new and used ultrasound systems all of which come with a full day of on-site systems and applications training.  To ensure your success, with every purchase, you also get an atlas, Musculoskeletal Ultrasound of the Foot and Ankle by Cozzarelli and Thapar.  

I agree with Doctors Kalker and Katz that if you have yet to purchase an ultrasound, you are missing out on a very valuable diagnostic tool.

Asa Phillip Hager, Sacramento, CA, AsaHager@gmail.com

Disclosure: Mr. Hager is employed by Universal Ultrasound.

ASSOCIATE POSITION – BROOKLYN, NY

Busy medical office in Brooklyn seeking part-time podiatrist. Good conditions. (718) 259-6666 phone (718)259-7000 fax, email zg0109@yahoo.com 

PODIATRISTS CHICAGO/NW IND/BALTIMORE/WASHINGTON, DC

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 Jake Shimansky, Director of Physician Recruitment. Phone-773-342-5221 FAX 773-486-3548-E-Mail jshimansky@homephysicians.com www.homephysicians.com

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes. Top hospitals. Fax CV with references to 703-491-9994

ASSOCIATE POSITION – MINNESOTA

Well-established podiatry clinic located in the Twin Cities area has an immediate opening for a full-time podiatrist.  The clinic is located just minutes from a surgery center as well as 2 major hospitals. Associate position is also open for partnership or purchase. Please email CV and inquires to rmccoy@associatedpodiatrists.com

ASSOCIATE POSITION - NW IOWA (SIOUX CITY AREA)  

Well-established, diverse, growing practice. Excellent referral base. Seeking an ethical, hardworking, motivated, caring podiatrist to fill a full-time position. Multiple hospital affiliations. Generous income with room for growth, leading to partnership for the right candidate. See our community  www.siouxlandchamber.com. Fax  CV, resume, three references to 712-258-9977.

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 POSITIONS - INDIANA/OHIO

PrimeSource Healthcare is a leading provider of mobile, on-site healthcare services at long-term and skilled nursing facilities. Our exceptional growth has created an immediate need for traveling, independent contractors of podiatry services in Indiana/Ohio. Earn between $175k and $225k per year. E-mail CV to kwright@pshcs.com. Visit us at pshcs.com.

PRACTICE FOR SALE- SEATTLE, WA

Beautiful office for sale in the heart of Seattle, WA. Newly renovated, 2,500 sf, new digital x-ray, vascular lab, state of the art physical therapy equipment, paper-less system, all new podiatric furniture and equipment, popular podiatric products store and beautiful diabetic shoe display. Office is located in the medical building and open 3 days a week. Great opportunity for expansion to full-time. Please send us a letter of interest to the: podiatrygroup@yahoo.com

ASSOCIATE POSITION-INLAND EMPIRE, CA

Busy 2 office multi doctor practice looking for dedicated, dependable, honest doctor to work 3-4 days per week. Must be ABPS BC/BE. Send cover letter and CV to bkatzman2@earthlink.net

ASSOCIATE POSITION FULL-TIME - SUBURBS OF CHICAGO

PSR 36 - month-trained podiatrist needed for busy suburban Chicago practice. Office and diagnostic equipment state-of-the-art. Full benefit package included. If interested, please fax your curriculum vitae to 847.352.0270 or email to foot1st@yahoo.com

DIABETIC RURAL OUTREACH PROGRAM - FLORIDA AND GEORGIA Seeking DPM to join our program due to a high demand for Podiatric Care to off-site settings in SNF, ALFs and House Calls. Applicants must be willing to travel and must have experience. Current State License, Medicare and Medicaid numbers required. Seeking highly motivated individuals who can be team players, yet work independently. Must have strong work ethic and excellent communication skills. APPLY: Fax CV to: 866-258-9993 include 3 professional references. Please provide the geographic area where you can provide services. Further information call 800-779-8551 or email: info@DROPInternational.org. Visit our website

ASSOCIATE POSITION – RESEDA, CA

Podiatrist needed in Reseda, CA office 2-3 days/wk, 6hrs/day @ $375/day to senior community. Please have an active Medicare #. Position starts immediately. Please email CVs to coasttocoastpodiatry@yahoo.com

ASSOCIATE POSITION - FREDERICK, MD

Well-established and growing 2 office state-of-the-art practice located in medical/professional buildings. EMR, Digital X-ray, Ultrasound, DME provider, etc. Competitive Base Salary plus bonus, malpractice, health insurance, etc. PSR 24 minimum/Board Qualified or Certified with ability and desire to take ER call. If interested, forward CV to DOCSBNB@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.

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

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

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