The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

November 18, 2006 #2,744 Editor-Barry Block, DPM, JD

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Morris A. Tatar, DPM

Morris A. Tatar, DPM passed away on November 5, 2006. Dr. Tatar practiced in Pittsburgh, PA for more than 50 years. He graduated from the Illinois College of Chiropody in 1952. He was a co-founder of the Podiatry Hospital of Pittsburgh and spent many years as a clinical instructor.

Dr. Morris A. Tatar

Dr. Tatar was a diplomate of the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. He was a fellow of the American College of Foot and Ankle Orthopedics and Medicine. He was a lifelong member of the APMA and PPMA. He was recognized by the PPMA as a Pioneer of Podiatry in 2005.

PM News policy is to request that memorial donations be made to the APMA Educational Foundation Student Endowment Fund, 9312 Old Georgetown Road, Bethesda, MD 20814.

Synthetic Shoes are Fungus-Friendly: VA Podiatrist

Sweaty feet can cause more than just smelly shoes. Our feet contain a high concentration of the body's sweat glands (3,000 of them per square inch).

Dr. Robert J. Baglio

"If moisture collects in the shoe," warns Robert J. Baglio, DPM, a foot and ankle surgeon in Charlottesville, VA, "it could lead to a number of skin issues, including athlete's foot." And wearing synthetic shoes that don't breathe puts you at risk for developing foot funguses.

Source: Eleni Gage, Reader’s Digest [December 2006]

Confusion Reigns Regarding HIPAA and Minors

One plea often heard from covered entities (CEs) is for relief from the patchwork of state privacy laws, which conflict, overlap, confuse and confound compliance with the national privacy regulation. A new survey reveals some commonalities in state law when it comes to the privacy rights of minors.

Generally speaking, CEs must comply with both state privacy laws and the federal privacy rule. CEs must determine which is more protective of a person's rights and follow that one. When it comes to minors' rights, however, only state laws apply, according to the federal privacy rule.

Follow the correct law. Minors may cross state lines for treatment. Pay attention to the law in the place of treatment, not the law in the minor's home state or where the insurance carrier or other payer resides.

David Ermer, managing partner of Gordon & Ermer, a D.C. healthcare law firm recommends the following guidelines:

*Make time to comply with any requests from parents or legal guardians. Request that a parent or guardian seeking PHI put that request in writing, which will allow time for the matter to be researched.

*Contact the provider if there is any question about whether the parent is the personal representative of the minor, as he or she may not be acting. The physician would know if the parent has been involved in treatment decisions.

*Check with the local hospital, physician and health plan associations to find out if new laws have passed affecting minors, and if any court cases have been decided. If they don't track such matters, suggest they start.

Source: Report of Patient Privacy [November, 2006]

Query: Consent for Reps

At the end of surgery, we were scheduled to place a pain pump into the patient's foot. The OR supervisor would not allow the rep to enter the OR. The reasoning was the patient had to sign a specific consent allowing this rep to be present during this part of the procedure. Isn't the rep technically a healthcare professional and an integral part of providing medical care? Doesn't my consent which states, "...and assistants" cover all medical personnel in the OR? Or are we required to have a consent signed by the patient specifically for these reps. It is helpful for these orthopedic and surgical reps to be present during our surgeries. They are very knowledgeable in regards to their products.

Dale Shrum, D.P.M. La Quinta, CA

Editor’s comments: PM News does not supply legal advice. The issue is whether a rep is an assistant. Most courts would interpret "assistant" to mean a “medically-trained assistant.” While it’s true that many reps might be very knowledgeable in the use of the equipment they are representing, it’s also possible they might be new on the job, and thus more trained to sell a product than to help in its use.

Several years ago there was a big brouhaha when it was revealed that some reps had actually participated in surgical procedures. The best way to deal with this problem in the future is simply to add “equipment representatives” directly to your consent form.

RE: Case of the Broken Needle Point
From: Allen Jacobs, DPM

I thought the PM News readers would like to know that the "case of the broken needle point " (PM magazine November/December) in a fifth toe went to court in St. Louis County. The jury returned a defense verdict in less that 45 minutes.

Allen Jacobs, DPM, St. Louis, MO, drjacobs0902@sbcglobal.net

RE: Hydroxyurea Side-Effect (Ira Weiner, DPM)
From: Rob Snyder, DPM, Jeffrey Kass, DPM

An additional side-effect of this medication is lower leg ulcer formation; I have seen no literature regarding treatments for this except to discontinue the drug.

Rob Snyder, DPM, Coral Springs, FL, DrWound@aol.com

Three treatments come to mind for chemotherapeutic neuropathy. Dr. A. Lee Dellon has done extensive research on neuropathy. His treatment consists of decompression of the common peroneal nerve, a "full" tarsal tunnel release as well as a deep peroneal nerve release. A non surgical option would be Anodyne therapy. A "medicinal" approach would be something like Metanx, a combo of L-methyl folate, Vit B6 and B12.

All have their pros and cons, limitations etc. There is documented proof of success with all treatments and literature can be reviewed.

Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com

RE: EPF Complication (Daniel Tellum, DPM)
From: Greg Mowen, DPM

It does sound like the lat. branch of the tibial nerve may be at least compressed. NCV/NCS have up to 45% error rate in evaluating the plantar nerves. If you have access to a PSSD test this would give you a better determination of nerve injury. I agree with the need for neurolysis. You will probably need to open up all four tunnels (tarsal t., med pl, lat pl and calc.)

Greg Mowen, DPM, Margate City, NJ, gregmowen@comcast.net

RE: Rape of the Plantar Fascia (Allen Jacobs, DPM)
From: Multiple Respondents

I was somewhat amazed by the recent article as well in Podiatry Today. I believe that within the article there probably is some truth to the "plantar fasciosis" tale of thickening of the plantar fascial band over time. However, the primary biomechanical mechanism and etiological process needs to be recognized. This is an inflammatory condition. Steroids do work if placed properly within the plantar fascia. Orthotics and taping do help to reduce the pronatory forces at work that create this condition in the first place.

If a patient were to obtain an MRI of the foot, inflammation would be seen near the insertion of the plantar fascial band to the calcaneus. I am not arguing that some "cases" of plantar fasciitis may indeed be a nerve entrapment, or possibly an inflammed bursa. However, the majority of patients I treat can and do respond to the "conventional" treatments of the day. This just seems to be an attempt to reinvent a new name for an old condition called plantar fasciitis.

Nicholas Brown, DPM, Wooster OH, nb78910@yahoo.com

Dr. Jacobs' well written posting strongly reinforces the need to exhaust non-surgical management of "Plantar Fasciitis" aka "heel pain." I would suggest, as Dr. Barrett states, that the foot specialist needs to sharpen diagnostic skills and treat the primary cause not just the symptoms. Granted, the immediate relief of acute pain will help the healing process, but the use of steroids and pain relievers for chronic problems may not be in the best interest of the patient. It may even be compared to "hospice care" - just keep the patient comfortable.

Dr. Barrett also suggests we improve our terminology. It is impossible for fibrous connective tissue to become inflamed! The word termination "itis" denotes inflammation. The word termination "sis" denotes a process, action or condition.

In as much as tendon, ligament and fascia are composed of fibrous connective tissue, maybe tears should be addressed as sprains (acute, subacute or chronic) or ruptures. The treatment would depend upon the extent of the problem and in the foot, the weight of the patient.

Jack Glick, DPM, MHA, AFO LAB, jglick@afo-lab.com

When the standard of care for treatment of plantar fasciitis is discussed I find it curious that no one mentions the treatment of the serious athlete. Many cases of PF will resolve in 6-8 months with conservative care but try to get the athlete to stop his sport for 6-8 months and you will never see him again. I will only try conservative care on athletes (injections, nsaids, strappings, PT, and orthotics) for 6-8 weeks at best. I have found the EPF to be the most effective treatment with ESWT no longer covered by insurance. I always use a medial incision and never cut more than the medial 2/3 of the plantar fascia leaving the lateral band intact. If the lateral band is cut many times a calcaneal-cuboid fault will occur destabilizing the lateral mid tarsal joint. This can be treated using orthotics with a calc-cuboid bar.

Barrett E Sachs, DPM, Plantation, FL, Uncletenose@aol.com

In reading Dr. Stephen Barrett's recent article in Podiatry Today, he makes the point that possibly earlier surgical intervention should be considered for treatment of plantar "fasciosis", instead of the more conservative treatment approach recommended by the American College of Foot Surgeons. Unfortunately, there was not any mention within Dr. Barrett's article of the body of scientific research that shows that plantar fasciotomy can lead to major alterations in the biomechanics of the foot during weight-bearing activities. This research, along with mechanical modelling of the foot, has led me to conclude that the plantar fascia has many important mechanical functions ( Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters, Precision Intricast, Inc., Payson, Arizona, 1997, pp. 45-46).

The ten vital mechanical functions of the plantar fascia are as follows:
1. Serves to stiffens the longitudinal arches
2. Assists the deep posterior compartment muscles in decelerating subtalar joint (STJ) pronation
3. Assists the plantar intrinsic muscles in decelerating arch flattening and accelerating arch raising
4. Reduces tensile forces in plantar ligaments
5. Prevents excessive interosseous compression forces on dorsal aspects of midfoot joints
6. Prevents excessive dorsiflexion bending moments on metatarsals
7. Assists in resupination of STJ during the propulsive phase of walking
8. Passively maintains digital purchase and stabilizes proximal phalanges in sagittal plane
9. Reduces ground reaction force on metatarsal heads during late midstance and propulsion
10. Helps to absorb and release elastic strain energy during running and jumping activities

Certainly, if Dr. Barrett had wanted to give a more biomechanically sound and balanced discussion of the proper staging of plantar fasciotomy for “plantar fasciosis”, then he should have also made an attempt to review the scientific literature regarding the negative mechanical consequences of plantar fasciotomy on the human foot.

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

PRACTICE FOR SALE – ASPEN COLORADO

Part-time practice seeing patients between 2 and 4 days per month. Grossing over $100k. Low Overhead . Last year when staffed 4 days a month, consistently grossed $140k. Fully equipped rooms in approximately 600 sq. feet. Open to any offers. 970.471.2049 mjs10vail@aol.com

EQUIPMENT FOR SALE - Stryker Command II

Set is in excellent condition. Includes console with cable, model 2296-88 wire driver, oscillating, reciprocating, and sagittal saws and 50k drill with hand switch control, 5/32" Jacobs chuck, 0.7mm -1.8mm wire collet, and 2.0mm - 3.2mm pin collet. $5,000. (Lists for $20,000) 503-313-1196 or cseuferling@comcast.net

ASSOCIATE POSITION - NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multilocation practice looking for PSR-36 associate leading to partnership. PSR-36 trained podiatrist with great opportunity for reconstructive surgical practice. Practice has Medicare-approved surgery center. Must have excellent interpersonal skills. Excellent salary and incentive. Respond to: westsidefoot@yahoo.com

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