The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

December 19, 2006 #2,769 Editor-Barry Block, DPM, JD

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Shoe Should be "Protective Container" - MA Podiatrist

High heels, which throw the weight toward the front of the foot, can cause the Achilles tendon at the back of the ankle to shorten and disrupt the mechanics of walking, said Dr. Peter Paicos Jr., a podiatrist and associate medical director of the wound healing center at Winchester Hospital.

Dr. Peter Paicos. Jr.

A shoe is supposed to be "a protective container," said Paicos. "But we spin fashion into it, so that changes what the container does." Badly fitting shoes may not pose a serious problem in young people, he added, but in older people who may already have trouble walking, they can make a bad situation worse.

Source: Judy Foreman, Boston Globe [12/18/06]

Universal Health Coverage: MA Plan Prompts Nationwide Interest

Massachusetts' universal health care plan might become a political and structural model for a federal health care initiative as the national health care debate "has reached a turning point, with both liberals and conservatives ready to compromise," the Boston Globe reports. Healthcare is likely to be an issue in the 2008 presidential election as Massachusetts Gov. Mitt Romney (R), an "architect" of the state's plan, is considering a presidential run, according to the Globe.

Other states' interest in the plan "is also pushing the health care issue to the forefront," the Globe reports. John McDonough, executive director of Health Care for All, said two dozen states are considering universal health care plans based on Massachusetts' plan. According to the Globe, "Liberals are setting aside old demands for a single-payer system, while conservatives are showing a willingness to consider more government involvement in the provision of healthcare."

Sen. Edward Kennedy (D-MMA) and Rep. Edward Markey (D-MA) have said they would push congressional hearings on using the Massachusetts program as a national model. Massachusetts Health and Human Services Secretary Timothy Murphy said he has been overwhelmed with states' requests to discuss the plan. "Massachusetts is going to do one flavor of health care reform, and other states are going to look and do something that fits their needs," Murphy said, adding, "[W]e clearly have reignited the healthcare debate across almost every state capital" (Susan Milligan, Boston Globe, 12/18).

Source: Susan Milligan, Boston Globe via American Health Line [12/18/06]

Jan 15, 2007 – Super Bones/ Super Skin Bahamas (Learn More/ Earn More) http://www.superbonesconference.com/ FILLING UP FAST- LIMITED HOTEL SPACE

Jan 18, 2007- Codingline Seminar NY (Pre Clinical Conference), NYC, NY (Multiple topics) www.codingline.com/events-ny.htm FILLING UP FAST

Feb 10, 2007 -New Mexico Podiatric Medical Association, Albuquerque, NM (Multiple topics) www.angelfire.com/nm2/nmpma

April 22, 2007- APWCA National Meeting, Philadephia, PA (Medical Legal Aspects of Wound Healing www.apwca.org

For a list of all meetings go to: www.podiatrym.com/meetings.pdf

Query: Botox For Hyperhydrosis

Are any of my colleagues in the Podiatric community performing Botox injections in the foot for treatment of hyperhidrosis? If so, what is the technique or where can I find information on the technique? Are there any training seminars on this subject? I have done a Medline search and there is a paucity of information/articles on this subject.

Emanuel M. Haber, DPM, Paramus, NJ

Editor’s note: We have reprinted an article titled “Application of Botox® for Pedal Hyperhydrosis” by By Mostafa Niknafs, DPM & Mohsen Khoshneviszadeh, DPM which appeared in the August 2005 issue of PM. View it at:
http://www.podiatrym.com/pmarticle.cfm?id=104

RE: Assistant Salary Survey
From: Lynn Homisak, PRT

Invariably, at almost every venue I speak, I am asked by doctors what the benchmark is for staff salaries. Due to the many variables [such as location of practice, experience and training, years on the job) that need to be taken into consideration, it is difficult and unfair to generalize whether a quoted salary is low, average or high. Neither is there a scope of practice put in place or formal schooling for podiatric medical assistants that would determine salary recommendations based on knowledge...as there is for example with medical or dental assistants.

The American Association of Medical Assistants has produced their own survey on their website and likewise, I'd like to conduct one specific to our podiatric profession. A study of this particular data will offer a current, valuable benchmark for all, based on the criteria mentioned above. I will produce an article for Podiatry Management magazine based on your combined results once all have been received so you can be informed of this national benchmark and other data queried in the survey. Realizing your time is extremely valuable, I very much appreciate your taking a moment to respond to this brief anonymous survey (only one response per office please). The more responses we receive, the more accurate the results will be, so I encourage you all to please participate. Please go to http://www.zoomerang.com/survey.zgi?p=WEB225YAWBU3UT to begin survey.

Lynn Homisak, Renton, WA, LynnPRT@msn.com

RE: Difucan Dosing (Larry Dorman, DPM)
From: Multiple Respondents

Normally I dose 100 mg. three times weekly, e.g. Mon/Wed/Friday for three months. If the patient has any question of impaired liver disease or any abnormal liver function test, I dose once per week for 12 weeks. This is also my regimen if they take more than a small dose of a 'statin', e.g. greater than Lipitor 20 mg.

In general, I do not do LFTs while the patient is on the regimen, but I do see them monthly and get a history, e.g. stomach problems, jaundice, cramps, etc.

Sloan Gordon, Houston, TX, sgordondoc@sbcglobal.net

In this case you may wish to try topical Diflucan 1% in DMSO and have the patient apply to the nail plate QD. Be sure to shake well prior to each application.

Jim DiResta, DPM, James.J.DiResta.DMS04@Alum.Dartmouth.ORG

RE: Peroneal Brevis Split (Dale M. Smith, DPM)
From: Multiple Respondents

A PB split is most often caused by a "pulley type wearing" of the tendon as it passes around the fibula. It is more often seen in a rearfoot varus foot type. If symptomatic, it can be "fixed" by direct inverted suturing and immobilization for about 4 weeks. In the past year, we have treated more than ten cases with TOPAZ coblation with the aid of musculoskeletal ultrasound.

Lowell Scott Weil, Sr., DPM, Weil Foot & Ankle Institute, weil4feet@aol.com

A peroneus brevis tear/split usually results in chronic pain laterally, most commonly occurring at the level of (or proximal to) the malleolus. As with any tendon tear, secondary to inflammation and continued mechanical stress, the tendon can rupture completely (as I have witnessed). Bracing is really best accomplished by a double upright brace attached to the shoe or an in shoe AFO. Neither of these will likely result in pain resolution in this case due to the quite severe extent of the tear. Of course, rupture of this tendon can be devastating in allowing an unopposed tibialis anterior to pull the foot into a varus position. I believe this patient would be better off with the “radical” surgical approach to repair this tendon (if she is a suitable surgical candidate).

Tim Vogler, DPM, High Point, NC, Timothy.Vogler@cornerstonehealthcare.com

The peroneus brevis and peroneus longus are the only extrinsic muscles of the foot that have a significant pronation moment arm across the subtalar joint (STJ ) axis. The peroneus longus has been measured, in a cadaver study, to have a STJ pronation moment arm of 21.8 mm, while the peroneus brevis moment arm has been measured to be 20.5 mm (Klein P, Mattys S, Rooze M: Moment arm length variations of selected muscles acting on talocrural and subtalar joints during movement: An in vitro study. J. Biomechanics, 29:21-30, 1996). As such, the peroneals are the only muscles that have significant ability to act during stance phase to counterbalance excessive STJ supination moments that may occur from other sources, such as that may arise from a high degree of metatarsus adductus deformity, rearfoot varus deformity or forefoot valgus deformity (Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001).

I have found that patients that develop peroneal tendon injuries, such as a split in the tendon of the peroneus brevis, that also have no history of trauma, nearly always have a type of foot that may possess excessive STJ supination moments. These patients routinely respond quite favorably to conservative therapy that is based on increasing the STJ pronation moments from a foot orthosis or other type of in-shoe wedge. This might include the use of custom foot orthoses fabricated with a valgus forefoot wedge, a lateral heel skive, an everted balancing position and/or increased medial expansion plaster thickness to lower the medial longitudinal arch of the device. When combined with appropriate immobilization therapy and physical therapy, I have successfully treated many patients with MRI-diagnosed peroneal tendon splits with this type of foot orthosis, without the need for surgery.

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

RE: ESWT Studies (Peter Riznyk, DPM)
From: Robert Scott Steinberg, DPM, Marc Katz, DPM,

Here is what is obvious. The tech committees and medical directors of insurance plans are free to play G-d. It doesn't matter to them whether the FDA has approved a treatment or not. They are free to label a specific treatment as "experimental" if for no other reason then to deny coverage, or in our case, to just stick it to podiatrists. They fell all over themselves accepting the flawed Buchbinder study, suspending all scientific sense, having found a perfect "excuse" to say high energy ESWT (HE-ESWT) did not work. Add to that some of our own colleagues, who fell all over themselves to test - research - low energy ESWT (LE-ESWT), that at best, seems to only offer temporary pain relief. This too added to insurance companies' list of excuses.

Though we followed a carefully prescribed treatment protocol before using HE-ESWT, and though results have been nothing short of spectacular, I have read on this forum, negative comments about HE-ESWT only to find out that many of those posting had little or no experience using HE-ESWT.

Maybe it is time for the APMA to file suit claiming that the only reason HE-ESWT is not covered it because podiatrists are using it.

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

The hard fact is that ESWT is experimental. The equipment is expensive. The outcomes are all over the place. When I used the modality, I had moderate temporary success. I've talked to some Docs that say they have 80% success, others say 20%. And of course, there are some that 100% success!

There are those that have interests in surgery centers and don't care what their outcomes are as long as they can pump patients into their centers for added profit. I know that this has ruined it for all podiatrists in Tampa.

The insurance companies are aware of all of these practices and the fact that podiatry does not typically do studies. Podiatry also has a history of abusing treatments, including alcohol injections, diagnostic ultrasound, etc. and of course now, ESWT.

If you truly believe in ESWT and it is not covered, have the patients pay cash. While they pay cash, the believers need to do "real" studies. I believe Dr. Weil is already in the process, but others will need to follow.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

Editor's note: This topic is now closed

POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

Multi-office, multi-doctor, well-established practice near the beach cities. Seeking a board eligible/certified PSR-24 or PSR-36 trained foot and ankle surgeon. Well-rounded practice requiring knowledge in biomechanics, pediatrics, sports medicine, diabetic wound care, trauma, and reconstructive foot and ankle surgery. Full-time position available immediately with generous compensation and benefits, including malpractice, and health insurance. Two-year commitment required with partnership opportunity. Send CV to akemfoot@sbcglobal.net or fax to (310) 838-0227.

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multi-location 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

ASSOCIATE POSITION – SOUTHERN WISCONSIN

Thriving Southern Wisconsin practice looking for an ethical, hard-working and highly trained podiatrists for an associate position at a well-established practice. Applicants must have completed a 2-year residency and be trained in all aspects of podiatric medicine. Strong potential for future partnership opportunity. Please fax CV and cover letter to (608)829-1319 or e-mail us at footdr@madisonpodiatrists.com.

ASSOCIATE POSITION - FINGER LAKES REGION UPSTATE NY

Leading regional group practice seeking ABPS residency-trained associate with partnership in mind. Excellent compensation/benefit package. Associate to see the same patient mix as partners, and will be involved in expanding the practice. State-of-the-art wound care center. Surgical privileges in nearby PA. Great opportunity for a well-trained, ethical podiatrist to work in a beautiful area that is great for family. NewYorkAssociate@comcast.net

ASSOCIATE POSITION – NEW YORK CITY

Looking for an enthusiastic well-trained foot and ankle surgeon to join busy Manhattan/Brooklyn practice leading to partnership. Candidate must have completed a minimum two-year surgical residency program, demonstrate qualities of self-motivation and have impeccable skills in forefoot and rearfoot surgery. Package includes malpractice ins. health ins. plus salary. Terms negotiable. Email Manfootcare@aol.com or call 917-756-3686

ASSOCIATE POSITION - CINCINNATI, OHIO

One of the largest podiatry practices in the United States is again in need of a PSR 24-36 Associate. All present doctors are in their thirties with similar training. Everyone is treated equally and there is definitely no limit to your success. Please submit resume or contact Karen Roesch via email or phone. Kroesch4poh@aol.com (513) 729-4455

ASSOCIATE POSITION- MEMPHIS, TN

30 year-old, high volume, multi-office practice in Memphis, looking for 24-36 PSR trained individual. Good opportunity for reconstructive surgery and wound care. No nursing homes or weekends. Potential partnership opportunity. Contact Footdok4@gmail.com

ASSOCIATE POSITION/ MANHATTAN AND LONG ISLAND

Seeking well trained podiatrist to help expand existing surgical practices. Candidate must be able to acquire staff privileges. Package and terms are negotiable, flexible hours. Email PODO2345@AOL.COM OR CALL (516) 476-1815

EQUIPMENT WANTED – USED X-CELL X-RAY UNIT

Used X-cell midbase Podiatry X-ray unit with orthoposer, Expected price. $3000.00 Mark Robson, DPM, Austin TX. 512 585-0242 mrobsondpm@aol.com

ASSOCIATE POSITION--PHOENIX SUBURB

Attractive opportunity for enthusiastic, proficient, and personable associate. Well-established modern practice with multiple newer spacious offices, technology and equipment. Solid referral base, close to hospitals, knowledgeable certified staff. 22% MCR. Practice and surgical center partnership potential opportunity. Prefer 24-36+ PSR. Send CV: AZpodassociate@aol.com

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