The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

December 12, 2009 #3,725 Publisher-Barry Block, DPM, JD

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Strengthening the Feet Will Not Correct Biomechanical Problems: Pribut

Stephen Pribut, a private-practice podiatrist in Washington, DC, shows some of his patients how to boost their foot muscles by picking up a towel with their toes. However, he maintains that "you're not going to un-pronate your foot by exercising any muscle in your foot."  Over-pronation -- or excessive rolling inward of the foot -- happens because of bone structure, he explains. In other words, some biomechanical problems will not be corrected by strengthening the feet.

Dr. Stephen Pribut

Pribut, who also sits on the board of advisers for Runner's World magazine and is a former president of the American Academy of Podiatric Sports Medicine, suggests that only runners with a certain arch shape should attempt running barefoot. "Some people's feet are just built for needing guidance" from shoes, like people with low arches, he explains.

Source: Rachel Mahan, Jewish Exponent [12/10/09]

WV Podiatrist Arrested on Drug Charges

Dr. Scott James Feathers, 54,  Parkersburg, was arrested Thursday afternoon by agents of the Parkersburg Violent Crime and Narcotics Task Force. Feathers was arraigned on a felony charge of delivery of a controlled substance by Wood County Magistrate Brenda Marshall, who set his bond at $50,000 surety.

Dr. Scott James Feathers arraigned on a charge of delivery of a controlled substance (Photo: Jeffrey Saulton)

According to the criminal complaint filed in magistrate court, Feathers allegedly sold Hydrocodone to a confidential informant in October at his practice and residence at 218 Gihon Village in Parkersburg. If convicted, he faces a maximum penalty of 1-5 years in the state penitentiary and a fine of not more than $15,000.

Source: Jeffery Saulton, News and Sentinel [12/11/09]

New Year's Eve: An Opportunity to Show a Year of Thanks to Your Staff

For the past several years, I have returned to our practice, during after-hours on the night before New Year's Eve, and left a bottle of champagne on the desk of all of our office team members. What makes it all the more special is a note which I include and tape to the bottle, which lists ten reasons it has been a great year. Number one is always, “Because of You!” The other nine to list are easy if you look at all the blessings in your practice. I also tape a $1 scratch-off lottery ticket.

It’s all about the office team. They are so important to our success and reputation.

Source: Hal Ornstein, DPM, Howell, NJ. For information on the American Academy of Podiatric Practice Management click here.

Query: Getting Patients for PRP Study

I am interested if any colleagues are using platelet-rich plasma for plantar fasciitis/Achilles tendinitis and/or other foot problems. I have the opportunity to participate in a pilot study and would be interested to see how others have “advertised” for patients, etc.

David M Davidson, DPM, Buffalo, NY

Query: Coding Multiple Fusions

How would I code the following?: Right medial column fusion involving the talonavicular, naviculocuneiform, and first tarsometatarsal joint. In addition, a second tarsometatarsal joint fusion and detachment repair of tibialis anterior tendon.

Robin Kubik, CPC, Brighton, MA

Response: The surgery you've described involves fusion of multiple tarsal and metatarsal joints.

Use CPT 28730 (arthrodesis, midtarsal or tarsometatarsal, multiple or transverse) for the fusion of all the joints you list.

In my opinion, it would be reasonable to also bill for repair of anterior tibial tendon detachment using CPT 28208 (repair, tendon, extensor, foot; primary or secondary, each tendon).

Howard Zlotoff DPM, Camp Hill, PA

Codingline subscription information can be found at:
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RE: Bone Scan (Charles Morelli, DPM)
From: Wm. Barry Turner, BSN, DPM, Charles Morelli, DPM

I am not a radiologist, but I imagine it (the bone scan remaining "hot") would be a while. A regular three-phase bone scan, in my mind, is almost like a "sed rate." Helpful, but not overly specific. Each patient is going to heal at their own pace. I am not sure why you would want to follow a patient with three-phase bone scans. If I knew that, I might be able to be more specific.
 
One quick note, I order WBC cell-tagged bone scans to evaluate effectiveness of therapy for a bone infection.  WBC cell-tagged bone scans can show you the absence of a bone infection, and I continue treatment until the WBC bone scan comes back clean of infection. I would expect the WBC-tagged cell bone scan to be negative within 48 hours of the resolution of the infection.
 
Wm. Barry Turner, BSN, DPM, Royston, GA, claret32853@gmail.com

My question was simply academic. Dr. Mullen was correct when he suggested a CT scan, since that is what I did, and it revealed that the arthrodesis was gapping plantarly due to my choice of fixation (which was inadequate). If the site was still "hot", then I would have considered removing the old fixation and replacing it with a stronger and more stable and compressive construct. If it was "cold", then I would know that this approach would not be successful, and I would have to consider other options. 

As the surgery was five months ago, clearly the Tc99 would be "hot" (according to Dr. Weil), and would not provide me with any helpful information. The CT scan combined with flouroscopy-guided intrarticular injections of anesthesia have enabled me to determine other sites that have been contributing to her symptoms, and treatment is continuing. I would appreciate any input.
 
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com

RE: Indomethacin for Acute Gout? (Elliot Udell, DPM)
From: Multiple Respondents
 
I have had excellent results with 1/4cc Kenalog injection dorsal aspect 1st MPJ and Tolectin DS x 10 days. If the fasting uric acid is over 6, then prescribe allopurinol 300mg q AM.

Pete Harvey, DPM, Wichita Falls, TX, pmh@wffeet.com

I can't begin to tell you how many patients I've had over the years who come in with their Indomethacin and/or colchicine prescription bottles in hand still suffering from their attacks.  Either they got no relief, or the GI problems were so severe they had to stop taking the medication. At the risk of the discussion evolving into one like the 12 different ways to treat warts, the protocol which has worked very well for me is 375 mg. Naprosyn every 8 hours. It is well-tolerated and significant relief has been noted anywhere from 1-2 doses to 2-3 days at the most.

Brandon Macy, DPM, Clark, NJ, bmacydpm@comcast.net

It has been found in one study that naproxen 500 mg twice a day is as effective as prednisone 35 mg daily [Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C: Use of oral prednisone or naproxen for the treatment of gout arthritis: a double-blind, randomized equivalence trial. Lancet 371(9627),1854-1860 (2008)].
 
My usual protocol is to give an NSAID, and a back-up prescription of colchicine 1.2mg followed by 0.6mg until resolution or side-effects with no more than a total of 6 pills taken. There may soon be a new player called febuxostat, which is a non-purine selective inhibitor of xanthine oxidase and considered more safe and effective than colchicine. We shall see. Although the gold standard is SF analysis, I rarely do it.  I just can't put a patient through that type of pain if everything points to gout.  If in doubt, the joint gets tapped.  There should be some exciting new ultrasound diagnostic tools coming up that could be used in many cases in place of SF analysis.
 
My protocol with initial attacks unknown to the primary is to get the ball rolling and treat the acute attack, provide them with a diet for gout, obtain appropriate labs 10 days after resolution (including uric acid levels), and get them and this information over to their primary care doctor. I keep in mind that the gout attack is merely a manifestation of a metabolic disease. There are other things that can cause elevated uric acid levels, such as cancers, and I certainly wouldn't want to miss a septic joint. It's not a condition I play around with. I get the patient comfortable, rule out other causes, get the ball rolling and get them to their primary doctor, who will hopefully treat this as the severe but treatable disease it should be recognized as. 
 
Jonathan B. Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Heel Pain in Marathoner (Scott Whitman, DPM)
From: Cary M Zinkin, DPM

Chances are that no matter what the podiatric physician recommends, the man is going to run the marathon anyway. He has an overuse injury, which all of us marathoners quite understand. He has a good chance of tearing his plantar fascia fully if he runs the race. There is nothing like a self-induced fasciotomy to give a runner a good few months rest. I do not believe that a cortisone injection is going to help him at all, since as soon as he gets 5-7 miles into the race and warms up, he will either feel better from the stretch (false sense of security) or much worse.

I am the last physician to want to sideline a runner, however, I believe you should note it in your chart that you recommend that he reschedules the race  and strap him up well the night before...tell him just to rest the few days before the race since he has been tapering anyway.

Cary M Zinkin, DPM, Deerfield Beach, FL, czinkin@aol.com

RE: Late-Arriving Employees (Name Withheld)
From: Jeffrey Conforti, DPM

I have had a few problem employees over the 23 years of practice. I was always hesitant to fire certain ones because of the need for long-term training of the new hires to learn the computer programs or other areas vital to the office work flow, etc.
 
I have found that the only person vital to the office is me. Every time I had to let someone go, and hired a new person, the office did much better. As to a time clock, get one. You are the Boss. Your office is NOT a democracy; it is a dictatorship. But, you have to be a benevolent dictator. There can only be one chief, and hopefully that chief is YOU. If your employees do not respect you, it is detrimental to the office. If something bad happens in your office while you are not there, your time card machine will tell you who was there. 

You always have to weigh the good vs. the bad in an employee. I have an employee who is constantly late, but is a very hard worker (and good worker, which is not the same thing), her lateness does not negatively impact the office, and she is always there when the office needs her to be there.          
 
Jeffrey Conforti, DPM, Clifton, NJ, jconfortiusa@yahoo.com

RE: NJPMS Sues Insurer Over Changes in Coverage (Robert, Bijak, DPM, Ronald Werter, DPM)
From: Michael Forman, DPM, Jeffrey Kass, DPM

Dr Bijak recommends one of our schools to take DPM's in as students and give them an MD degree. Novel idea. However his last paragraph states, "We can't wait for them to take us in. We need to make our own pathway." I see those as contrary beliefs. I believe we should look at the dental model. They do not want to be MD's. They want to be dentists and have developed their own pathways and techniques that make them unique in medicine. 

The concept that a podiatrist is not qualified to read a sonogram is ludicrous. Let's not allow that to happen.

Michael Forman, DPM, Cleveland, OH, im4man@aol.com

Dr. Werter brings up one of the many "plagues" of dealing with insurance companies. They do what they want. It does not have to make sense. What recourse is there? I attend podiatry meeting after podiatry meeting and voice these concerns. There are a host of other problems, such as insurance companies allowing for orthotics, but not allowing podiatrists to make them. Who are we really supposed to complain to, and how do we change things? BTW, Dr. Werter, you will find out if you haven't already, that Cigna is not the only insurance company that does that.

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

RE: Healthcare Reform
From: Thomas Nolen, DPM

There was a proposal to extend Medicare to those 55 to 64 years old a few days ago, but it would cost $764/month vs $100/month for those 65 and over on Medicare. How is that fair? Also, how is it fair that only those 65 or over are entitled to Medicare without regard to their physical or financial situation? To be fair, Medicare should be for everyone or no one.

Thomas Nolen, DPM, Centralia, IL, nolendpm@yahoo.com

PRACTICE WANTED- NYC/LI AREA

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 f-massuda@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 - SOUTHEAST GEORGIA & SOUTH CAROLINA

Seeking recent residency graduate to join practice. Must be PSR-24/36 trained. Multiple locations. Full range of services with new facility. Fax cover letter & CV to (843) 208-3348 or E-mail to melissafoot@pol.net
 

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 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.

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