The Voice of Podiatrists

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November 26, 2009 #3,711 Publisher-Barry Block, DPM, JD

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Prevention is the Best Defense for Dance Injuries: FL Podiatrist

Being ‘light on your feet’ when dancing is not entirely true; dancing the night away can take a toll on feet and ankles. Both professional and amateur dancers can suffer foot injuries that can stop the show, as witnessed this season on the popular reality-television show, Dancing with the Stars. 

Dr. Amber Shane

According to the American College of Foot and Ankle Surgeons, the most common types of dance-related foot and ankle problems are overuse injuries, which occur due to the repetitive movements in dance. “Over 50 percent of dance injuries occur in the foot and ankle. The severity of the damage is determined by a patient’s age, strength and flexibility, and the type of shoes worn when dancing,” Orlando-area foot and ankle surgeon Amber Shane, DPM, FACFAS, said.

With dancing being repetitively hard on the lower extremities, how can dancers of any level protect their feet and ankles? “The best defense to injury is prevention. Dancers should wear appropriate shoes to properly support their feet and ankles as well as perform dance moves with their individual skill levels in mind,” Dr. Shane said.

Permanent Nail Removal For Distance Runners Not The Norm: FL Podiatrist

"One of the top problems [ultrarunners face] is the toenail issue," said Dr. Matt Werd, a Lakeland, FL, podiatrist and past president of the American Academy of Podiatric Sports Medicine.

Dr. Matt Werd

There are many types of toenail trouble. Toenails turn black and blue from friction and wear -- from rubbing against the sock or from hitting the toe or even the top of the sneaker. Blood can accumulate underneath the nail and lift the nail off the nail bed, making the nail prone to falling off. Blood can also pool beneath the nail and cause pressure, which causes pain. Blisters can form underneath the nail. A fungal or other infection can take root in the nail bed.

Any and all of these problems can warrant toenail removal, Werd said. But unless they become chronic issues, permanent removal is not usually the suggested treatment. And even then, it's far more common for a runner to have only the offending nails, not the whole set, removed permanently.

Source: Jack McCluskey, ESPN 11/23/09]

FL Podiatrist is Part of Team to Save Horse's Life

Abby can thank her veterinarian, Valerie Biehl, for a second chance at life. The 6-week-old foal was born Oct. 7 with Neonatal Maladjustment Syndrome, or NMS, which is caused from lack of oxygen to the brain. Horses with this condition rarely survive without human intervention as they need to be nursed and supplemented with plasma and antibiotics. But Abby was given a new lease on life thanks to around-the-clock care from a team of medical professionals.

Dr. David Haile

Abby needs braces that allow mobility for her legs to straighten and grow properly, Biehl called upon her friend, Sebastian podiatrist David Haile who, up until now, had worked on only one other animal — a giraffe at Busch Gardens. He said Abby is like a child with a club foot. Alongside Billy Owings, his orthotics specialist, Haile volunteered to design braces for Abby.

Abby with Leg Braces (Photo Sam Wolfe)

Source: Lawrence Gould, TC Palm, [11/23/09]

Desert Foot Conference 2009 for the VA Breaks All Previous Records

The Desert Foot Meeting took place in Tempe, Arizona Wednesday through Friday last week and hosted over 500 attendees from across the country at the high tech Buttes Marriott Conference Center. The creme de la creme in diabetic limb salvage from the VA systems and elite academic centers provided 3 days of lectures and workshops to predominantly VA podiatrists and nurses.

Dr. Allen Jacobs lectures at Desert Foot Meeting

Esteemed faculty included Conference Chair Robert Frykberg, DPM, MPH, Co-Chair Jeff Robbins, DPM, David Armstrong, DPM, PhD, Dane Wukich, MD, past ADA President Lee Sanders, DPM, Allen Jacobs, DPM, Lee Rogers, DPM, Nick Bevilacqua, DPM, Warren Joseph, DPM, James Felicetta, MD, Vivienne Halpern, MD, Cynthia Fleck, RN, Jeff Karr, DPM, and Charles Anderson, MD.

Attendees overflowed the tiered lecture hall into an adjacent simulcast room where lectures were broadcast in high definition video. The exhibit hall was filled to capacity with 77 companies who provided their latest scientific leadership to this influential group.

Engage Listeners to Increase Buy-In

To educate listeners and to engage them are entirely different processes. If your goal is merely to pass along information, follow the classic three-step model: Tell them what you are about to tell them, tell them, and then tell them what you told them. If, however, your goal is to engage listeners’ interest and participation, you should present information differently:

First, ask them what is important to them right now. Next, tell them what you can do to move them toward their goals. Finally, ask them how they would use your information, ideas, or products.

Bottom line: When they understand and envision using your ideas, they begin to buy in.

Source: Adapted from Ultimate Sales Tool Kit, William “Skip” Miller, AMACOM via Communication Briefings

Query: Osteomyelitis

I am looking for surgical treatment recommendations for a 64 yo male with diabetic neuropathy. He has a history of open puncture wound (screw through work boot) plantar right third/fourth metatarsal head. The MRI notes osteomyelitis third and fourth metatarsal head, and third/fourth proximal phalanx base of each toe. He states he only wants to be "cut on once”, “I do not want to be whittled on." His circulation is WNL.

Osteomyeltis

What treatment is best? 3rd/4th MTPJ resection? 3rd/4th ray amputation? Transmetatarsal amputation? Other?

Richard Frost, DPM, Spokane, WA

RE: Adolescent Verucca Treatment (Chris Seuferling, DPM)
From: Multiple Respondents
 
A biopsy must be done post haste. If these lesions are verruca, they appear to be of the mosaic form which in my younger patients have responded to topical applications of formalin 10% applied daily.

Lawrence J. Sturm, DPM, Hallandale, FL, lsturm@bellsouth.net

I use a combination of debridement, application of monochloracetic acid and pulsed-dye laser treatment performed every 2 weeks. I have the patient apply 20% formalin in the mornings and debride the lesions themselves in the evening before applying 60% salicylic acid ointment at night under occlusion.
 
I have not had a child who did not respond eventually. It will also work without the pulsed-dye laser but will take longer. I have not found Aldara to be effective on plantar warts.
 
Ken Meisler, DPM, New York, NY, kenmeisler@aol.com

In my experience, these type of multiple verrucae in an adolescent respond well to sub-lesional injection(s) of Candin (candida skin test). Mix 0.1cc of Candin with 0.5cc of plain Xylocaine, inject the primary lesion. Re-appoint for 3 weeks, no other treatment. Debride if necessary, and repeat the injection as necessary. If it is successful, the lesions will simply disappear after 1-4 injections.

Ron Footer, DPM, Gaithersburg, MD, drfooter@comcast.net

If there are at least 50 ways to treat warts, clearly there is no one best way. Although invasive, I have had success with difficult cases like this using the carbon dioxide laser. This procedure requires proper training and experience. If done properly, there is no scarring. You might also consider oral cimetidine therapy in conjunction with laser treatment.

Evan F. Meltzer, DPM, Jackson, MS, Evan.Meltzer@va.gov

RE: Metanx and Epidermal Nerve Fiber Density Testing (Arthur Lukoff, DPM)
From: Nicholas Sol, DPM, Jeffrey Kass, DPM 

Dr. Lukoff raises several important questions to consider regarding this new approach to diagnosis and treatment of diabetic peripheral neuropathy. He questions the need for the biopsy instead of simply prescribing Metanx. I'm of the opinion that simply prescribing Metanx would be "second best" to a more deliberate protocol. In our office, we do not prescribe Metanx without histological evidence of diminished nerve fiber density and/or nerve fiber degeneration. If indicated, Metanx is prescribed for a six month trial after which follow-up biopsies are performed to assess efficacy.

Regarding the cost argument, both biopsies are specific for small fiber neuropathy and together approximate the cost of a single, more painful EMG that is biased toward large fiber disease. Regarding the efficiency argument, polypharmacy is an endemic problem in geriatrics. If biopsies confirm both the indication for Metanx and its efficacy, the patient is taking a therapeutically necessary medication. Interestingly, Dr. Jacobs’ data demonstrates measurable nerve fiber density increase after six months of Metanx therapy in some patients with 0 fibers/mm at the onset of therapy. That is nerve fiber regeneration. None of the other medications for neuropathy have demonstrated any degree of regeneration. That addresses the good medicine argument.

Many of these patients are taking multiple medications for symptoms of neuropathy. Our protocol does not wean patients off of other neuropathy medications until after histologically demonstrated efficacy. Then we begin to taper down amitriptylene, Neurontin, Lyrica and/or Cymbalta, thereby reducing both cost and polypharmacy.  Improving nerve fiber density appears to make better clinical sense than simply improving tolerance of this progressive disease. At least it does at this time. We'll see how this protocol evolves.

Nicholas Sol, DPM, Colorado Springs, CO, drsol@thewalkingclinic.com

Why do ENFD testing? One great reason is you can now have the ability to identify someone who is going to become neuropathic but at present may not be symptomatic. A second reason is you can identify patients for whom there is a better likelihood of reversing the effects. (To date, I am only aware Metanx has this capability.) Thirdly, in my practice, I have come across a few patients that come in complaining of "painful feet" and found nothing that I was able to pinpoint a logical reason for their pain. All of those patients were positive for small fiber disease.

Why do the test and not just put them on Metanx to begin with? It’s a valid question - I think in today's litigious society it is better to document as much as possible. What if the pain wasn't small fiber disease? You may have lost valuable time in treating whatever the real diagnosis was - you'd potentially find yourself in hot water that way.

This has been stated numerous times before in this forum but as a whole, our profession seems to underbiopsy. In 2 years of residency training, I do not recall performing one biopsy. There is nothing wrong with a biopsy - go do some.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

Editor's note: Disclosure In the previous discussion on Mentanx, it was inadvertantly omitted that Dr. Allen Jacobs is a paid consultant for Pamlabs, the manufacturer of Metanx. 

RE: Custom vs. Pre-Fab Orthotics (Robert Bijak, DPM)
From: Andrew Cassidy, DPM, MS

I am continually amazed when podiatrists such as. Dr. Bijak state that there are no differences between custom and OTC orthotics. As a profession, we are the experts in foot biomechanics and should act accordingly. Let us list some of the benefits of a good custom orthotics vs. OTC devices.

1. Casting the foot in neutral vs. pronated position allows for an impression of the foot in the position it should operate in, and then design the device to bring the ground up to meet the foot. In addition...

Editor's Note: Dr. Cassidy's extened-length letter appears at: http://www.podiatrym.com/letters2.cfm?id=30717&start=1

RE: Automated Appointment Reminder Systems (Douglas F. Tumen, DPM)
From: Harry E. Confer, DPM

Check out Office Ally.com. For under 500 patients per month, their charge is $29.95. For Over 500 patients, it is a bit higher. You have control on when the appointment reminder call occurs.

Harry E. Confer, DPM, West Covina, CA, drhec@aol.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 - PHOENIX, ARIZONA

Part Time/Full Time, ethical and hard working graduate of a PSR 24+/36 Residency to join our growing multi-location practice. Good mix of Surgery/Pediatric/Trauma. Very modern offices with EMR, U/S, Digital X-Ray, ESWT, ABI Testing. Excellent referral base, and a well-trained staff. Base salary, bonus structure, benefits. Current AZ License a Must. Please e-mail CV and references to azpodiatrists@hotmail.com

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.

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

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

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.

PRACTICE FOR SALE - CENTRAL SOUTH CAROLINA

Practice grossing $400,000 annually based on one full-time doctor with two offices. Surgery is currently about 10-15% but can easily be increased. Medicare makes up 52% of revenues. May be able to take over practice with no money down. Interested parties email to footdocsc@gmail.com

ASSOCIATE POSITION - MINEOLA, NEW YORK

Full-time associate position with future partnership potential available with busy multi-office practices on Long Island. Must be proficient in all phases of podiatry with emphasis on surgery, biomechanics and RFC. Minimum standards include either a three-year PSR, or board qualified/certified status with ABPS. Existing hospital privileges with a NY based facility helpful. Interested doctors are encouraged to e-mail their CV to mets724@gmail.com

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

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