The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

December 22, 2009 #3,733 Publisher-Barry Block, DPM, JD

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MA Podiatrist Discusses Plantar Fasciitis

Dr. Tom Lyons, a podiatric foot surgeon at Beth Israel Deaconess Medical Center in Boston graciously provides this information about plantar fasciitis. "The plantar fascia is a supportive thick band of tissue that extends from the heel, out along the bottom of our feet, and it eventually branches out and connects to our toes," Lyons explained. "It helps to maintain the arch in the foot, sort of like a tie beam you'd see in your attic or maybe a church. It ties the front (forefoot) to the rear foot (heel) and supports the arch, preventing it from flattening. The plantar fascia assists the foot in acting as a shock-absorbing mechanism when we walk and run...Most patients I see will come in and simply say, 'My foot hurts.' That could mean any number of things," said Lyons. "When I ask them to describe the pain, I have a pretty good idea whether we are dealing with plantar fasciitis, which is an inflammation of the plantar fascia, or something else."

Dr. Tom Lyons

"A tight Achilles can pre-load the stress on the plantar fascia, so it's important to stretch your Achilles," Lyons said. "I don't recommend standing on a step and dropping your heel. A better stretch is keeping your foot flat on the floor and knee straight as you lean toward a wall. "Arch support is often necessary. You should definitely avoid bare feet and hard flat shoes. Raising the heel is good. Some of my women patients are very excited to hear that, but I also remind them that not all high-heeled shoes are made equal and can lead to other foot problems."

Source: Gary Gillis, MLB. Com [12/17/09]

CA Podiatrist Kisses Pig For Charity

Forget the swine flu epidemic, San Diego podiatrist Richard Green had to kiss a hog whether he wanted to or not. He was the winner of a “Kiss the Pig” contest held by San Diego Rotarians.

Dr. Richard Green (center) kisses pig for charity.

They donated $1,500 to a scholarship fund in the name of a club member they would most enjoy seeing smooch a swine. Green won the vote, but the pig stole the show. Fred Baranowski swears that Green made the piglet squeal when he puckered up …

Source: Diane Bell, San Diego Union-Tribune {12/19/09]

Diabetic Foot Ulcers Tied to Earlier Death: Study

Among people with diabetes, those who develop foot ulcers seem to die earlier than those without the complication, a new study finds. Lead researcher Marjolein M. Iversen, of Bergen University College in Norway, stated, "Our study revealed that a history of foot ulcer is a significant marker of higher risk of death not only for people in hospital settings but also in community health care."

In the study, researchers found that among more than 65,000 Norwegian adults, those with a history of diabetic foot ulcers had a higher death rate over 10 years. Compared with other diabetic adults, those with a history of foot ulcers were 47 percent more likely to die during the study period. The risk was more than two-fold higher when foot ulcer patients were compared with non-diabetic adults.

People with a history of foot ulcers did tend to be older, have poorer blood sugar control and have higher rates of heart disease and stroke, depression and kidney dysfunction. But those factors only partly explained the higher death risk attributed to foot ulcers, the researchers report.
 
Source: Diabetes Care [December 2009] via Diabetes in Control

Query: Mal Perforans-Like Ulcer

My patient  is a 50 year old male with CMT & associated peripheral neuropathy who refuses to wear a brace. He walks with high steppage gait due to drop foot. He wears off-name brand, minimally supported sneakers. He does not want to buy better shoes/inserts or orthotics or wear any gel cushions, etc. He presented with a mal perforans-like ulcer/covered with callus.  He wants a procedure to stop this callus from recurring. He relates having had two surgeries: The first was 35 years ago to correct bunion and curved toe. The second was 5 years ago to remove bone from under the callus to prevent its recurrence.  ROM at the 1st MTPJ is WNL. ROM at DIPJ is non-existent-auto fused!

X-rays of affected toes

RE: Post-Operative Tremor S/P Metatarsal-Cuneiform Exostectomy (Sloan Gordon, DPM)
From: Charles Reilly, DPM, Peter Bregman, DPM

The tremor noted may be more a splinting phenomena much like other "protective" spasms we see. Does the tremor occur when the foot is dorsiflexed, thus decreasing the stretching through the operative site? A diagnostic local injection proximally of the deep peroneal nerve may confirm a local phenomena vs. a central or more proximal etiology-neuropraxia, secondary to the tourniquet. i.e., the nerve block may also be therapeutic by 'breaking" the spasm. If so, it can be treated as other spastic/protective splinting conditions we encounter. 
 
Charles Reilly, DPM, Chicago, IL, pododoc1@msn.com

Since this was so soon after surgery, you have to try to rule out something related to the surgery and certainly some type of UMN or brain infarct is something that should be considered in the differential diagnosis. Looking at where the incision is, I would recommend a Marcaine block of the superficial peroneal nerve just above the ankle to see if that relieves the tremors. If not, then try the common peroneal and see if that helps. Obviously, this will point you in the right direction one way or another. I would probably put her on Cymbalta or Lyrica, or maybe even cyclobenzaprine if the injections do not work, or leave that to the neurologist. I will be curious to see how this turns out.

Peter Bregman, DPM, Tewksbury, MA, drbregman@gmail.com

RE: Congenitally Deformed Fifth Toe (Paul Kruper, DPM)
From: Jeffrey Kass, DPM

The bone to be removed is the bone causing the pain. I place an 8mm x-ray lesion marker directly over the site of pain and x-ray it. Depending on which bone is involved, you can do an arthroplasty or simple exostectomy. While there are always more than one way to fix something, I have learned staying simple is always good. In your particular case, while you can do what you mentioned, there is also the option of simply rasping the protruding bone and leaving the toe in its current shape. Good luck either way, and if you can, let us see your post-op films when totally healed.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

RE: Osteomyelitis? (Wm. Barry Turner, BSN, DPM)
From: Marc Katz, DPM, Simon Young, DPM

There are several considerations in this patient. First, since the patient was neuropathic, these are likely fractures with healing and not osteo. In my experience, white cell scans can light up with this kind of destruction as we often see in Charcot. Also, the fact that there was no wound would be a consideration for fracture/Charcot vs. infection. Lastly, I would have reconsidered the antibiotic choice. Cipro has poor coverage for gram positive infections, and prolonged use can lead to MRSA. You could have combined the Cipro with clindamycin. However, I would have considered IV treatment if you did indeed determine that this was osteomyelitis.

I would also comment that while CBC, CMP and sed rate are important, it is possible that all could be normal even with infection as we see often with diabetics who are immune-compromised.

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

The ID people I deal with do not treat chronic OM with any antibiotics. It isn't warranted. The nearest clinic is approximately 1 hr away. Did the patient have family who could drive her? Patients in NYC travel 45 min – 2 hrs to see a doctor all the time. Distance and time is no rationalization. The cost of antibiotics is a consideration, but you must use the appropriate antibiotic, not any antibiotic. I am sure that most hospitals offer indigent care waivers. Your motives are righteous and intent reasonable. The outcome could've been much worse.

Simon Young, DPM, NY, NY, simonyoung@juno.com  

RE: Anthony Grieco, DPM

Anthony Grieco, DPM died on December 18, 2009 at the age of 86 from leukemia. Anthony served as a medic in the USAF during WWII, flying the sick and wounded and logging over 2,000 hours. He was a Temple University Podiatry School graduate in 1948. He practiced in Hoboken, NJ for over 45 years. He was a former member of the Hudson division of the NJ Podiatric Medical Society. He started the podiatry dept. at St. Mary Hospital in Hoboken, NJ, and served as chief for 15 years. He welcomed young, newly-practicing podiatrists to the medical staff. He had a great passion for golf and was an amateur champion in New Jersey. He is survived by his wife, Dolores.

Joe Boylan, DPM, Ridgefield, NJ

RE: Handling Office Emergencies (Bryan C. Satterwhite, DPM)
From: Multiple Respondents

In the 30+ years that I have been in private practice, I had to perform CPR twice: once for a patient in the waiting room, and once for a patient who had a cardiac arrest in the treatment room. Both survived and both were taken to the hospital by ambulance. The speed at which my staff recognized the problem and I responded to it made the difference between life and death for each of these patients.
 
In both cases, which were more than two years apart, my staff and I coordinated it well. 911 was called the moment I started CPR, and when  the emergency medical team arrived, the patients were breathing, alert, and had no idea what had happened to them. After all was said and done, the one who most shaken was me. Had I not been in the right place, at the right time, and not had a staff who were alert to what was happening, the outcome could have been tragically different. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

I'm connected to a hospital, so we keep oxygen, epinephrine, ammonia inhalants, and "the basics." The ER is a few hundred feet away. I'm trained in ACLS and CPR, however, when we have a serious emergency (only 3 in 25 years, Thank God), we call 911 which I think is the most appropriate action.

Years ago, we had a full emergency kit and I am trained in how to administer most of the drugs. We had a patient suffer a grand mal seizure and I gave the patient IV diazepam and used a tongue stick (easily made with a tongue depressor and 4x4s). However, times are different and how you respond to an emergency depends on your skill level and the local standard of care. In Texas, there is no Good Samaritan law, so even stopping for an MVA to render aid, which I did once and performed CPR, brought that to light. The EMS guys who knew me, said "doc, take off, so we don't have to put your name down, otherwise you could be liable if the patient doesn't make it." 

I would check with your state board, local DPMs, and residency director along with an ACLS instructor to see what's required.  You might also want to call your liability carrier.  Please follow up with us on the listserv as this is a critical issue.

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

This is one of those slippery areas in that if you've never taken the course to become ACLS-certified (or beyond) and know how and when to push some of the meds in your crash box, you may be better off not having it in the office. Dr. Block (and others) would be more readily able to comment on the legalities of this, but I'm of the opinion that you may be held liable for an untoward outcome if the patient could have been saved or salvaged with the use of epi, atropine, etc., you had it in the office and didn't use it. The excuse "I didn't know how" in this case is true and may or may not have consequences. I've always wondered about this topic, the fact that many of these meds are delivered IV, no one I know of has an IV start kit in their office--although they may have the IV meds at hand--or bags of NS or RL at hand.

I'd like to hear from our legally-trained colleagues on whether it is better not to have these items in the office if you are not prepared or trained to use them?

David Secord, DPM, Corpus Christi, TX, david5603@pol.net

Editor’s comment: PM News does not provide legal advice. It would be wise for all practitioners to be aware of the “Good Samaritan” laws that are in effect in their state. These laws dictate one’s potential liability or lack thereof when treating an emergency.

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

DREAM PRACTICE OPPORTUNITY - OKLAHOMA

Use forefoot, rearfoot, wound skills in ideal small city with nearby lake. No buy-in costs. No limit on income. EMR. Act fast. OK State License deadline is 1-30-10 and test is comprehensive. Personality preferred over ego. Email julietburk@gmail.com or call 918-931-1425 for details.

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 - 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

EQUIPMENT FOR SALE - DIAGNOSTIC ULTRASOUND

MINDRAY DP-6600 Diagnostic Ultrasound for sale. 7.5 Mhz linear transducer. Like new condition, less than 2 years old. Comes with mobile stand. Contact robdaughertyddd@yahoo.com or 573-979-1809 for further information.

PRACTICE FOR SALE – NE OHIO

Long established general practice. Grossing $300,000 annually with very little surgery. Modern, well equipped office in desirable location. Large diabetic patient base with DME. Excellent referrals with over 500 new patients per year. Great growth opportunity for surgically trained podiatrist. Owner will stay to introduce. Email: docjoc227@hotmail.com

ASSOCIATE POSITION - HUDSON VALLEY, NY

Excellent opportunity for a three-year surgically trained foot and ankle physician. We are a high-volume, diversified, multi-office practice utilizing state-of-the-art modalities. Ample growth opportunities for a personable and highly-motivated DPM with ability, and a desire to teach and take ER call. If interested, please forward CV to: healthyfeet4ever@yahoo.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.

EQUIPMENT FOR SALE

X-Cel MB-700 X-ray unit, All-Pro Processor, and Anodyne unit.
731-446-7285/E-mail nraines@charter.net

PRACTICE FOR SALE - TENNESSEE

Well established practice for sale. Full scope medical and surgical practice including DME. Exceptional practice with a high volume of new patients. Excellent hospital and surgical center privileges with investment opportunity. Great area for a family and the outdoorsman. 731-446-7285/E-mail nraines@charter.net

PRACTICE FOR SALE - CENTRAL FL

Practice and medical building for sale, in beautiful, high quality of life, growing area, Central Fl.; 2000 sf bldg. fully equipped/ designed for podiatry; excellent location, features & exposure; near hospital, wound and HBO center. Great opportunity for expansion & investment; good insurance climate. 352-223-2713 / E-mail: windnwave@earthlink.net

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