The Voice of Podiatrists

Serving Over 10,000 Podiatrists Daily

October 31, 2007 #3,080 Editor-Barry Block, DPM, JD

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Babies Should Not Wear Shoes Until They Can Walk: IN Podiatrist

Within the first year, a baby’s feet will grow approximately one-third of its adult size, said Dr. David Olson, a podiatrist for 35 years.

Dr. David Olson

“That’s the reason we don't have infants wear shoes (before they are walking) because the foot grows so fast that we don’t want to stunt foot growth or cause blisters,” explained Olson, whose practice is located in La Porte.

It can also be difficult to tell whether a baby’s shoe still fits since the child cannot say so. Olson advises turning the shoe upside down and placing the foot on the back of the shoe to see where it falls. “You can get a nice leather shoe that’s thick and comfortable and does not drag like a tennis shoe,” Olson said

Source: Mary Wellinski, Herald-Angus [10/29/07]

FL Podiatrist Launches Christmas Shoe Drive

A Delray Beach podiatrist will soon launch a “Share Your Soles for Christmas” shoe drive. Elizabeth A. Reilly, DPM, of Pineapple Podiatry is inviting families, businesses and church groups to participate. Pineapple Podiatry is seeking new or gently-used children's shoes of all kinds and all sizes as a part of the drive that begins Nov. 12. Reilly said the goal is to collect 300 pairs of new or slightly used children's shoes. These shoes will be distributed to charitable organizations that deal with needy families.

Dr. Elizabeth Reilly

“Many of our children have shoes for every occasion. We have heard of children in some South Florida communities who only have one pair of shoes and of other children who have only a single pair – one that falls off their feet. The 'Share Your Soles for Christmas' Children's Shoe Drive’ meets a serious need of children who do not have adequate footwear,” said Reilly “We want to be able to ‘put wings on the feet' of needy children."

Source: Dale M. King, Boca Raton News [10/29/07]

People Had Healthier Feet Before Shoes: South African Study

Researchers at Wits University recently announced the results of a study on the health of human feet, to be published in next month's issue of the prestigious journal, The Foot. The study demonstrates that people had healthier feet before the invention of shoes. The study - conducted by Wits academics Dr. Bernhard Zipfel, a podiatrist and curator of fossil collections, and Prof Lee Berger, of the Institute for Human Evolution and the Bernard Institute in the School of GeoSciences - reveals that early human populations who didn't wear shoes had healthier feet with fewer pathologies than modern groups of humans who wear shoes.

Dr. Bernhard Zipfel

The research was conducted on more than 180 modern humans from three different population groups (Sotho, Zulu and European) and on skeletons of humans more than 2 000 years old. The study challenges the widely held belief that habitually wearing shoes is good for your feet and suggests that going barefoot results in fewer bony pathologies, particularly in the mid-foot region.

The study also highlights the damage high heels do to women's feet. "In almost every case, women show a higher frequency of fore-foot pathologies, bony damage to the foot. This is almost certainly due to the constraining nature of fashionable female footwear and the wearing of high heels in particular," said Berger. The one exception to this is in Zulu men. The study shows that they have more foot pathologies than Zulu women.

Source: Pretoria News [10/26/07]

Query: Wound Healing Network

What are the experiences of podiatrists who have had either positive or negative experiences with Wound Technology Network?

Marc Katz, DPM, Tampa, FL

Query: Neuroma Injection Denial

I am getting constant denials from Medicare when billing CPT 64450 (peripheral nerve block, therapeutic or diagnostic) for an injection of a neuroma. The diagnosis code submitted is with ICD-9 355.6 (Morton's metatarsalgia, neuralgia, or neuroma).

Is our billing incorrect? This combination has always paid in the past.

Susan, Office of Gilbert Shapiro, DPM, Tuscan, AZ

Response: Arizona is a Noridian Medicare state. Despite our efforts and protestations, Noridian will (currently) not permit the use of CPT 64450 for injection of a local anesthetic and cortisone (specifically meeting CPT 64450's therapeutic definition) for cases of either interdigital neuroma or tarsal tunnel syndrome

If you review the Noridian local carrier determination (LCD) on "Injections of Peripheral Nerves," you will note that providers are directed to use CPT 28899 for such injections with diagnosis of "neuroma" or "tarsal tunnel syndrome." Reimbursement will be set at the equivalent to CPT 20550 (injection of tendon).

Rick Horsman, DPM, Olympia, WA

Codingline subscription information can be found at:
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RE: Surgical Power System (Greg Caringi, DPM)
From: Robert Bondi, DPM, Neil Levin, DPM

I use the Stryker core system at a number of facilities I work at and I think it is the best system to work with compared to the Zimmer/Linvatec system.

Robert Bondi, DPM, Lee’s Summit, MO, Robert.Bondi@Foot-Docs.com

Check out Micro Aire modular systems. Very simple and reliable. If you are used to Hall gas powered instrumentation, you will like their system.
Neil Levin, DPM, Sycamore IL drfeet1@aol.com,

RE: Supplier for Stainless Steel/Carbon Fiber Insert (Kurt Gustafson, DPM)
From: John Mishasek, CPed

An individual come to our pedorthic store with a significant ulceration of the distal residual foot post-TMA. This individual had been supplied TSD footwear 90 days earlier by a DPM's RN, and the individual said that he had no ulceration at the time the shoes were dispensed.

No rigid plate had been supplied for the shoe used for the TMA foot. No rocker soles had been added to the rather poorly constructed athletic shoes (weak heel counters and weak shank construction). So subsequently the front half of the shoe on the amputated foot was permanently dorsi-flexed almost 45 degrees, and with each step the leather upper would hit the ulceration area dorsally. The lateral heel counter was deformed to the point that extreme supination occurred at heel strike even though he had used the shoe for only 90 days.

The podiatrist who supplied the shoes had been doing weekly debridements of the ulcer for the past 7-8 weeks in his office but he had not recommended his patient cease using the shoe for a surgical rocker shoe or walking cast. The lack of modifications to the shoe and the lack of recognition of the premature failure of the shoe combined with my inability to have a healthy working relationship with this podiatrist caused me to suggest to the patient that he consider a second opinion from another podiatrist that we had seen to do superior diabetic ulcer care.

The patient did finally go to the other podiatrist, and we were told by the patient that he was immediately taken out of the TSD shoe for a CROW walker. He subsequently returned to our pedorthic store after the ulcer was healed with a Rx from the wound care center podiatrist for the patient to be supplied his TSD benefits here.

John Mishasek, CPed, Colorado Springs, CO, jmishasek@earthlink.net

RE: Pay for Performance (Lloyd S. Smith, DPM)
From: Multiple Respondents

I was surprised to read Dr. Smith's comments about pay for drug therapies only after it has been established that they work for particular patients. This strikes me as a bad idea for many reasons. I have never heard of a drug, a procedure, a PT modality, or any other treatment that worked uniformly for all patients. This scheme endorses the unrealistic notion that there is a one-size-fits-all cure for everything. Maybe I'm incompetent, but some of my heel pain patients don't get adequate relief from my initial modalities. That's why I have a protocol for treating heel pain that starts with cheap and non-invasive treatment which works for most patients. I only progress to more aggressive care when patients fail to respond to the initial treatment.

The same can be said for neuromas, tendinitis, warts, and many other conditions. If a therapy is indicated for a pathologic state; and if that therapy is delivered appropriately; then it is not reasonable to withhold payment for that therapy. In an effort to prevent a penalty, is also not appropriate to start with the most invasive and expensive therapy when most patients will be healed with less. The idea presented by Dr. Smith would certainly lead to this sort of ham-fisted medicine. Scoffing at the drug providers is short sighted because, if this sort of approach is legitimatized, it is only a short matter of time before we are attacked as well. We will soon be penalized for treating patients appropriately if they fail to respond. (And many patients do not respond because of their non-compliance.)

Do you think that some patients might deny that their pain is significantly decreased if they can recoup a few $40 co-pays by doing so? And if a cure is supposed to be guaranteed, I suppose a failure to satisfactorily respond to a medicine must be, you guessed it, malpractice! This would be just one more reason to avoid the truly sick and concentrate on young, healthy patients.

Richard Gosnay, DPM, Danbury, CT, beautifulbaldhead@hotmail.com

Dr. Smith cites something that is happening in Europe. Some national health companies are asking patients who receive drugs paid for by the respective national health company to report back at a certain time and if they indicate that they did not get results from the medication, the drug company may have to refund the money to the insurance company or may not get paid. There are pros and cons to this plan. On one hand it seems to cut down on costs of medications by making sure that the medications prescribed work. On the other hand, there are frightening problems.

Many years ago my internist gave me a prescription for some ailment. It did not work and I called the doctor’s office and the office manager and said "Elliot, firstly were you really taking the medication as prescribed?" I was a bit annoyed by that question, but now I look back and realize that she encountered many patients who did not take their meds and wondered why they did not feel better. Now had I not taken the medication as prescribed, it would not have been the drug company’s fault. Too many patients are not compliant.

Now if I was up against that national health plan that Dr. Smith described, they may have taken the medication away and made the drug company pay them back and where would that have left me as a patient? Also, we all know that not every medication works for every patient. With neuropathic pain, some people respond to Cymbalta and not to Lyrica. It’s not the drug company's fault. What about an antibiotic prior to a culture report coming back? If you picked the wrong one does this mean that the drug company will lose out?

This seems like "big brother in France of England" is nosing into the sacred and private doctor - patient relationship. Is this what we might expect if national healthcare comes to our shores?

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

The treatment whether it be physical therapy or medicinal should be able to demonstrate objective improvement. In a small pilot study several years ago, a board certified neurologist was able to demonstrate nerve conduction velocity improvement in diabetic patients the results of which were published in the Journal of the Diabetes Technology Society. NCV studies showed an overall improvement of 43% at 90 days and 47% improvement at 180 days. NCV studies showed that 23% of the non-responsive nerves became responsive by day 180. Specifically, 3% of the non-responsive sural nerves and 42% of the nonresponsive peroneal nerves became responsive. NCV testing showed that 47% of the nerves tested had improvement by 180 days. This included 40% of the sural nerves and 53% of the peroneal nerves.

At the beginning of the study, 11% of the 190 sites tested had a normal VPT testing. At 180 days, 44% of the 190 sites tested had a normal VPT testing. At the beginning of the study, VPT testing showed that 73% of the 190 sites had a LOPS (Loss of Protective Sensation). At day 180, VPT testing showed that only 39% of the 190 sites tested had LOPS. In addition, at day 180, VPT testing showed that 91% of the 190 sites had improved, compared to the beginning of the study. Analysis showed that there was a statistically significant improvement in the VPT results even after only one month of treatment (p <.001, Friedman test). This statistical improvement remained throughout the six-month study.

Donald A. Rhodes, DPM, Corpus Christie, TX, DrRhodes2@aol.com

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