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November 20, 2006 #2,745 Editor-Barry Block, DPM, JD

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High Platform Shoes Like Walking on Stilts: DC Podiatrist

Platform shoes could be the eighth architectural wonder. They are remarkable examples of design but, like most of the seven fabled monuments of the ancient world, surely these extravagant pillars of footwear cannot last. However exhilarating the shoe's concept, those wearers who equate inches with power must finally acknowledge the obvious: Platform defies function.

"It's like walking on stilts," says Washington podiatrist Arnold Ravick, or "falling off a hill. You're up so high that the center of gravity and balance is off. It's much harder to walk."

Dr. Arnold Ravick

The form is great, but function gives spike heels their appeal, according to Ravick. "The appeal is the way high heels make a woman walk," he says. Not so appealing is that "it's easier to fall off and break your leg." He considers two-inch platforms potentially safer than six-inch stilettos.

Source: Linda Hales, Washington Post [11/18/06]

Doctors Face Cuts While Others Gain

Without congressional action in the next few weeks, physicians will see reductions in Medicare pay next year, while other program participants get raises.

Source: Centers for Medicare & Medicaid Services

Hospitals Relaxing Ban on Cell Phones

Hospitals' cell phone use policies are less restrictive now that technology advancements have made devices safer to use near medical equipment.

Note: Figures do not add up to 100% due to rounding.

Source: Currentpath.com survey of 111 hospital engineer members of the Biomedtalk-L discussion list. Accessed Nov. 7 [via AMNews 11/20/06]

Query: AdvancedMD

We are considering switching PM software after many years with Cerner. We are looking at AdvancedMD and wondering if any others have used this and their experience with them. We are a small 2 doctor (husband and wife) practice in a very rural setting, but strive to keep our practice current and efficient.

Gregory Rouw, DPM, Fergus Falls, MN

Query: Hyaluronidase Injections For Post-Op Fibrosis

I've used Hyaluronidase/Wydase injections in the past for post-op fibrosis that may occur (MPJ stiffness after bunion or hammertoe surgery) and have found great success in dissolving the scar tissue and restoring joint ROM. Wydase has been discontinued and there is no generic hyaluronidase on the market anymore. Has anyone had any experience with Amphadase or Hylenex injections (both brand marketed hyaluronidase injections with FDA approval for opthalmic purposes) and how they compare with Wydase?

Rahul Patel, DPM Flushing, NY

RE: Open Book Policy (Bob Levoy)
From: Kathleen Neuhoff, DPM, DVM

I have had an open book policy with all my staff in my veterinary hospital (30 employees) for 25 years and my podiatry clinic (6 employees) for 12 years. We are a bit more advanced in the veterinary hospital where all employees are given figures including income, expenses, number of patients seen, income generated per patient, income generated per staff hour worked, income generated by each doctor individually, income per hour for all staff positions according to their skill level, etc. The staff at the podiatry clinic does not receive quite as much information, but receives as much as I generate.

We have had no problems with this approach. Our staff has a much more realistic idea of the income earned by our doctors than most practices Remember that staff KNOWS how much money comes in(after all, they collect those co-pays and balance the day sheets!). If they do not see the expenses, they assume that nearly all of that money ends up in the pockets of the doctors! So when they find out what we actually make, it is less than they thought we made.

We have had three instances of embezzlement or theft in my two practices. Each was caught by other team members (NOT an office manager) within two months and all money taken was repaid. They were caught quickly because in an open book system, it is much more difficult to "hide" missing money. Doctors are often too busy to bother with some of these details, but there are always detail oriented team members who notice a discrepancy much faster than we do!

I am a proponent of sharing as much information about the practice management with team members as possible. They realize that this sharing of information demonstrates respect and trust and they will reciprocate.

Kathleen Neuhoff, DPM, DVM, South Bend, IN, VETPOD@aol.com

RE: EPF Complication (Daniel Tellum, DPM)
From: Kevin A. Kirby, DPM

One of the many mechanical effects of plantar fasciotomy is that the loss of the strong tensile forces generated by the plantar fascia during gait will result in either an increase in active contractile activity of the plantar intrinsic muscles or an increase in passively generated tensile forces in the remaining plantar ligaments. The tensile force within the plantar fascia has been shown in a recent dynamic cadaver study to peak at a magnitude of 0.96 times body weight at the heel off phase of gait and (Erdimir A, Hamel AJ, Fauth AR, Piazza SJ, Sharkey NA: Dynamic loading of the plantar aponeurosis in walking. JBJS, 86A:546-552, 2004).

In addition, recent cadaver and finite element analysis studies of plantar fasciotomy have shown that stress and strain of both the long and short plantar ligaments are increased with plantar fasciotomy (Crary JL, Hollis M, Manoli A: The effect of plantar fascia release on strain in spring and long plantar ligaments. Foot Ankle, 24:245-250, 2003; Gefen A: Stress analysis of the standing foot following surgical plantar fascia release. J Biomechanics, 35:629-637, 2002; Cheung JTM, Zhang M, An KN: Effects of plantar fascia stiffness on the biomechanical responses of the ankle-foot complex. Clinical Biomechanics, 19:839-846, 2004).

Therefore, with this scientific research as a foundation, it also makes good mechanical sense that the demand on the abductor hallucis muscle, a muscle that helps prevent longitudinal arch flattening along with the short and long plantar ligaments, will also be increased after plantar fasciotomy. This increased mechanical demand may result in increased tension and volume of the muscle with resultant compression of the lateral plantar nerve that courses deep to it. Improved orthosis and shoe therapy would be my first choice in treating this patient.......not further surgery which could complicate matters for this patient.

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

Editor’s note: This topic is now closed

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

I commend both Dr. Jacobs' and Dr. Smith's comments. They are both right on. As for taking issue with Dr. Jacobs over the use of the term "rape", can we all lighten up over his metaphorical tone. In this case, the man basically represents mainstream podiatric thinking, which for this condition, works! Overwhelming anecdotal reporting by the majority of our colleagues indicate conservative plantar fascia management works > 80%. While ESWT and EPF certainly have their place in the overall treatment protocol for plantar fasciitis, it seems clear that Dr. Barrett's personal financial agenda has transcended his common sense and what is in the best interests of our patients. Who's the person that stands to financially gain the most from the potential gross over-utilization of the EPF procedure?

In addition to patenting the equipment, he also profits from the seminars he provides to ensure his colleagues properly utilize his patented equipment. While I take no issue with any of that, I do have a major issue with a colleague writing a self-serving article that has no factual basis behind it in a blatant attempt to circumvent an established, effective treatment protocol for the sole purpose of promoting his/her own product.

I would submit, that the traditional conservative management of plantar fasciitis works closer to 95%. The majority of failures I witness occur in those patients who were simply originally misdiagnosed, with nerve entrapment of one or more branches of the posterior tibial nerve, or more proximal nerve entrapment, specifically L5-S1 radiculitis, serving as the two most commonly encountered non-biomechanical heel pain etiologies I encounter.

It's rather sad to see one of our brighter colleagues place their personal financial agenda before our patient's best interests. Even in the best of hands, EPF's have certain complications associated with their utilization. It boggles my mind why an astute practitioner wouldn't recommend an efficacious, safe, conservative treatment course for any given condition, especially this one.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

I read Dr. Barrett's interesting and thought-provoking article re
plantar fascitis/osis. With all due respect to a podiatrist who probably has forgotten more on this topic than I will ever know, I simply cannot agree with his premise that there is no inflammation. I agree 100% that there is at least an element of degeneration, but I have treated many people with this using standard methods for this malady and they seem to do better.

A study recently undertaken came to the conclusion that scintigraphy is predictive of good results regarding injections. In areas of focal uptake as seen via scintigraphy, injections had a high success rate. The way I see it, a high focal uptake is similar to inflammation or at least strongly suggestive thereof.

John Spina, DPM, Brooklyn, NY, footdude325@hotmail.com

Two years ago at the ACFAS Annual meeting there was an excellent "Heel Pain Panel" of experienced foot and ankle surgeons who reviewed the surgical literature and found that EPF had a 82 % excellent result and small incision /open surgical approaches had 87 % excellent results. All plantar fasciotomy type procedures had a range of excellent results from 82-87%. The fact that we all have our own surgical techniques for this prevalent condition and still have the vast majority with excellent results means that there is NOT one technique that is really much better than another ....

Joe Agostinelli, DPM, Niceville, FL, jmpa21@cox.net

Editor’s note: This topic is now closed

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

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

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