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07/20/2020
RESPONSES/COMMENTS (CLINICAL) - PART 1
From: David Secord, DPM, Bryan C. Markinson, DPM
I’ve been using the Panacos graft and the bleomycin treatments ever since I first started practicing. I list these two together because they attempt to accomplish the exact same thing with somewhat different techniques.
Bleomycin technique: The bleomycin treatment is my primary treatment for verrucae vulgaris lesions and I currently have a 99.7% success rate over 8 years and hundreds of cases with the added benefit that if the person has multiple verrucae, treating just the one lesion will allow resolution of all...
Editor's note: Dr. Secord's extended-length letter can be read here.
The Panacos procedure was debunked 40 years ago. Search that procedure and you will not find one credible publication about it in any literature.
Bryan C. Markinson, DPM, NY, NY
Other messages in this thread:
05/01/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1B
RE: Functional Hallux Limitis
From: Howard Dananberg, DPM
Howard Bonenberger mentioned in a post last week that one of my lectures on functional hallux limitus (FHL) inspired him to treat patients with chronic postural complaints. I appreciate his comments and am glad he was able to find these concepts valuable. I have written extensively on FHL over my career, and have come to the realization that this concept remains misunderstood. The reason why it can impact postural form lies in the following principle. Once the hallux makes ground contact during any step, IT DOES NOT MOVE AGAIN UNTIL TOE-OFF. ln any form of hallux limitus (structural or functional), what is restricted is not the hallux, but the remainder of the foot and proximal structures all the way to the neck.
As the body adjusts for these motions, various sites are stressed repeatedly during each step cycle. And since these motions are repeated thousands of cycles per day, the stress becomes a chronic irritant. In particular, loss of MTP joint motion restricts heel lift, shortens stride length, and causes the ensuing swing phase to be altered in such a way as to make toe-off mechanically inefficient. Since the iliopsoas is the primary hip flexor at toe-off, and originates directly from the lumbar spine, it becomes the site of pain. The references for this are below.
Howard Dananberg, DPM
05/01/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1A
RE: Functional Hallux Limitis
From: Jeffrey Trantalis, DPM
Howard Bonenberger, DPM hinted about a very important and prevalent condition that is seen in many, if not all, podiatry offices. This is hallux limitus. In the early 1980s, I had a professional NFL receiver come to me with hallux limitus. It was obvious that conservative treatment was the only option. At that time, orthotics with a hallux extension was the recommended treatment. So I tried this very treatment, knowing it would probably fail. Well it did fail.
At that time, I dispensed an orthotic where I increased the ability to plantarflex the first metatarsal by supporting the 1st metatarsal-cuneiform joint. This allowed for a more normal function of the first MPJ. This was very successful treatment that allowed the receiver to make his route maneuvers.
Jeffrey Trantalis, DPM, Delray Beach, FL
03/13/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1
From: David T Weiss, DPM
The most powerful way to manage DPN, (besides glycemic control,) is refraining from sugar (and carbohydrates) completely - especially after dinner. Sugar is extremely inflammatory. I have recommended liposomal glutathione (powerful antioxidant) as a supplement, along with L-methyl folate vitamins.
David T Weiss, DPM, Richmond, VA
02/27/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1 A
From: Robert Scott Steinberg, DPM
Not only are there too many schools, but the curriculum has not kept up to the standards for today's podiatric physicians and surgeons to become successful in practice. Colleges are not teaching the courses necessary for podiatrists to sit for the USMLE board exams, keeping the profession under the hallux of others. I suspect the first podiatric medicine college offering a better curriculum will get far more applicants. Let the race begin.
Robert Scott Steinberg, DPM, Schaumburg, IL
02/12/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1 B
From: Khurram Khan, DPM
Small fiber neuropathy (SFN) and large fiber neuropathy (LFN) represent two distinct categories of peripheral neuropathy, differentiated by the size of the nerve fibers they affect and the resultant symptoms and diagnostic approaches. SFN targets small myelinated Aδ fibers and unmyelinated C fibers, leading to symptoms like burning, tingling, and is diagnosed through hstory/clinical evaluation. LFN affects large myelinated fibers responsible for proprioception and vibration sensation, and with diagnosis typically achieved via physical exam and confirmed with nerve conduction studies and electromyography (EMG). The patient mentioned seems to have SFN. The causes of small fiber neuropathy (SFN) include:
Diabetes, autoimmune diseases (e.g., Sjögren’s syndrome, lupus, rheumatoid arthritis, celiac disease), infections (e.g., Lyme disease, HIV, hepatitis C), vitamin deficiencies (particularly vitamins B12, B6, and E), alcoholism, toxic exposures (e.g., chemotherapy drugs, heavy metals, industrial chemicals), hereditary disorders (e.g., hereditary sensory and autonomic neuropathies, Fabry disease), idiopathic (no identifiable cause), and finally metabolic disorders (e.g., thyroid dysfunction, amyloidosis)
Khurram Khan, DPM, Philadelphia, PA
02/12/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1 A
From: Lawrence Rubin, DPM, Bruce I Kaczander, DPM
The sensory dysfunction referred to by Dr. Teitelbaum is called "paresthesia." I have had some patients even complain of a feeling of "bugs running up and down my feet and legs" and similar sensations. Here is more information: Paresthesia: When to pin down a cause.
Lawrence Rubin, DPM, Las Vegas, NV
In my 42 years of practice, I saw patients daily whose neuropathic symptoms were spinal in origin (stenosis, L 4-5, S-1 disc)… it can oftentimes present initially as same, without the patient having current spinal symptoms. They also may have a history of same years ago.
Bruce I Kaczander, DPM, Southfield, MI
01/18/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1 B
From: Richard D Odom, DPM
I suspect the patient is a smoker. If so, his smoking is likely the etiology or cause of his lesions. The reason is because smoking/anxiety can cause these in areas of the body where there are an abundance of sweat glands, plantar foot & palms of hand. This increased moisture leads to some of the glands being over productive and can cause blockage of the surface of sweat gland. Farther production moisture is unable to escape from the gland, leading to increased hyperkeratotic build-up and pain from weight-bearing.
Stopping the smoking will reduce the hyperhydrosis, thus allowing the majority of the punctate lesions to most likely resolve over a 2-3 months period of time. The main point is to control the hyperhydrosis to minimize the re-occurrence of these painful lesions.
Richard D Odom, DPM (Retired), Decatur, GA
01/18/2024
RESPONSES/COMMENTS (CLINICAL) - PART 1 A
From: Gary S Smith, DPM, Adrienne Sabin, DPM
I have had people improve greatly with Spenco insoles and spraying their feet daily with underarm antiperspirant spray.
Gary S Smith, DPM, Bradford, PA
Not knowing any other history of the patient, I suggest looking into Cowden’s syndrome as part of the differential diagnoses.
Adrienne Sabin, DPM, San Jose, CA
06/30/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1
RE: Low Tech Treatment for Heel Spur Deformity?
From: Richard Jaffe, DPM
On a trip to India, a common treatment for heel spur syndrome there was demonstrated to me by a local physician. A small, pointed hammer was heated and applied to the plantar heel, burning the skin.
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Low Tech Treatment for Heel Spur Deformity? |
The patient, who has had this treatment on two previous occasions told me that, in the past, it has helped her for about 2 years. Perhaps, if all else fails…
Richard Jaffe, DPM, Jerusalem, Israel
06/28/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1
From: Allen Jacobs, DPM
Generally, the medial malleolus does not begin to ossify until the seventh year. The differential diagnosis ranges from calcaneal valgus of infancy to occult tarsal coalition to any number of causes for chronic, progressive, collapsing foot deformity, such as ligamentous, laxity and associated disorders, compensating, deformities, and so forth.
Honestly, if you were asking such a question, it would be best that you refer the care of this patient for evaluation to those with more experience in the treatment of pediatric deformities of the foot.
Allen Jacobs, DPM, St. Louis, MO
06/22/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1C
From: David Secord, DPM
Every few years, the topic of prolotherapy seems to rear its head. The detractors point out that there are no studies establishing efficacy. Its supporters point out their level V (in the hierarchy of clinical evidence schema) success rates in their patient base. If anyone cares, here is some background:
From an interview with Dr. Paul H. Goodley, MD, by Carol Peckham Published: 08/19/2009:
Dr Goodley: Prolotherapy, [otherwise known as] regenerative injection therapy (RIT) or reconstructive ligament therapy, was developed about 60 years ago and is a fundamental, effective injection therapy for the repair of injured connective tissues, such as ligaments and tendons. Sclerotherapy and prolotherapy had previously been used...
Editor's note: Dr. Secord's extended-length letter can be read here.
06/22/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Elliot Udell, DPM
Glen, thank you for enlightening us on your successes with prolotherapy. Perhaps you can publish your technique as well as findings. If you can document that prolotherapy works, the treatment will no longer be in the realm of alternative healthcare. If the article is well written, there are many journals in our profession that would love to publish it. As for charges, I based this on what a certain non-podiatric physician in my geographic area was charging and it was well over a thousand dollars for each treatment. Some of these patients were quite upset after spending 10K, out-of-pocket, for a series of dextrose injections.
Elliot Udell, DPM, Hicksville, NY
06/22/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Robert Kornfeld, DPM
Dr. Ribotsky implores me to "publish my outcomes". But not having lived in my shoes, he does not understand. I will explain. There are 2 parts to the story. 1) I adopted a more holistic paradigm in 1987 after a chronic illness (which could not be helped by any conventional doctors for a few years) was healed and resolved within 3 months of seeing a holistic internist. I experienced the power of natural healing firsthand. I dove into learning everything I could and began experiencing its power on my patients.
I wanted to share this with the profession so I spent a number of years lecturing about the things I do to assist my patients to heal. Although I was invited to speak a number of times at large podiatric conventions, my efforts were not being well received by the podiatric community. So I started trying...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
05/24/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: David Secord, DPM
A few years back, I wrote a book on pain management, but never found a publisher. There was a chapter on the use of potentiation so that you could obtain greater effect from a narcotic and use a lower dosage via use of a potentiator drug. There are different categories (tricyclics, anti-psychotics, anxiolytics, SSRIs), but they work the same way (the explanation of which is too long to cover here.)
Navane (Thiothixene), Xanax (alprazolam), and a few others have been used to varying effect. When I did an office procedure in my surgical room, I would have the patient take a Vicoprofen (hydrocodone and ibuprofen) [now discontinued] with a 5mg or 10mg Valium (diazepam) (dosage dependent upon body mass) with food about an hour pre-op. The majority of the patients slept through the procedure and the ones who were conscious appeared completely at ease and relaxed. The one med would potentiate the effect of the other without increased mu receptor activation and respiratory depression.
David Secord, DPM, McAllen, TX
05/24/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Steven Finer, DPM, Walter Perez, DPM
Try increasing the Ativan to 2.5mg. or consider 10mg. of Valium which has a longer life. Watch out for interactions with other drugs. Also, patients sometimes complain of headache after Valium. It also has mild muscle relaxant properties.
Steven Finer, DPM, Philadelphia, PA
I have not prescribed anti-anxiety medication for a long time for any type of surgery, including bone surgery, but if I have a very anxious patient, I prescribe Valium 5mg, two tablets, and ask the patient to take one tablet with a sip of water 2 hours before the surgery and if still anxious the second tablet 1 hour prior to the surgery. But what I really believe helps the patient's anxiety is to prepare them for surgery thoroughly, explain to them what to expect at the surgical center or hospital, step by step, and address their questions and concerns. That will help patients stay more relaxed and comfortable. My advice is to spend time with the patient going through the surgery and the process, and you may not need anxiolytics. I try to avoid them and I usually let the anesthesiologist handle anxiety issues.
Walter Perez, DPM, Brooklyn, NY
05/04/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Wenjay Sung, DPM, Todd Lamster, DPM
That’s cancer. Prove me wrong; get a biopsy or send out for a biopsy.
Wenjay Sung, DPM, Arcadia CA
Regarding the unidentified lesion on the dorsal aspect of the foot, this lesion needs to be biopsied as soon as possible to rule out carcinoma. With its rolled border, I would guess that it is a basal cell carcinoma.
Todd Lamster, DPM, Scottsdale, AZ
05/04/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Thomas A. Graziano, DPM, MD, Alec Hochstein, DPM
There is not much history provided in the post regarding this "lesion" or even its duration. But in response to the poster question "any idea of what this might be?" I suggest a prudent approach would be first taking a biopsy of the lesion.
Thomas A. Graziano, DPM, MD, Clifton, NJ
In any seemingly healthy patient with a non-healing wound without specific etiology to point to for non-healing, a diagnosis of pyoderma gangrenous must be considered. Please keep us posted.
Alec Hochstein, DPM, Great Neck, NY
04/14/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Edith James, CPed
Pedifix’s Pediplast made into a custom toe separator could be the solution. Custom toe separators can be made to lift and prevent rubbing between toes plus significantly reduce contact with ground forces. These are formed directly to the foot, then cure in minutes. These last very well; some last for more than a year.
These combined with cushioned, moisture-wicking high tech fiber socks have improved the health of many patients. Note: thicker socks usually require more room in footwear, of course. Personally, if current socks are inadequate protection, my presentation of solutions starts with socks since they’re the first opportunity to help. Custom toe separators, protective cushioned socks, orthoses, then fit footwear are all that are needed here.
Edith James, CPed, St. Louis, MO
04/14/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Michael Orosz, DPM
I’ve recently started using a product from PediFix called Visco-Gel Hammertoe Crutch. These are especially effective for those patients with long toes that plantarflex over a crest pad.
Michael Orosz, DPM, Cedar Rapids, IA
01/09/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Howard Dananberg, DPM, Lloyd Smith, DPM
I’ve had a great deal of experience both as an avid skier and podiatrist. My recommendation is to consider semi-weight-bearing impressions for custom ski orthotics. The foot is very compressed within the ski boot and full control can be quite painful. Lowering the MLA via the impression technique is very helpful. And since the medial column of the foot controls the medial edge of the ski, 1st ray cutouts permit improved 1st metatarsal plantarflexion, thereby improving edge control without the need for excessive posting or arch support.
Howard Dananberg, DPM, Stowe, VT
I skied about 60 days a year for over 20 years. I improved my technique and comfort by working on my old rohador orthotics using layers of duct tape on the medial edge to determine the proper pronatory control. After finding the sweet spot to gain symmetry and edge control, I took them back to the office and added Korex posts to match. They are met head length and I inserted a flat insole to fill out the shell. They eliminated all foot pain and allowed me to ski on any trail I wanted.
The foot should not move in a boot. That causes foot fatigue and poor technique. You should be skiing with your knees and hips with additional balance from your upper body and poles. I found it challenging to design ski orthotics for patients. Without an expert boot fitter, it is difficult. As a result, I developed a close relationship with the fitter and most patients were satisfied.
Lloyd Smith, DPM, Newton, MA
01/09/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Robert Scott Steinberg, DPM
I have made ski boot-specific orthotics and have been doing custom boot fitting for over 30 years. I am a certified member of the Professional Ski Instructors of America, Rocky Mountain division. I worked with the Vail Ski School to refine the technique of using ski boot orthotics not only for support but to improve knee position and tracking. Making a proper orthotic for a ski boot differs from one for gait. When I put my running orthotics into my ski boot, my center of knee mass is misaligned!
I perform a full biomechanical exam. It is important to find any forefoot varus or valgus. Forefoot posting is all important. It determines the direction of knee travel, and it directly affects the alignment of the...
Editor's note: Dr. Steinberg's extended-length can be read here.
01/06/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Lloyd Nesbitt, DPM
Orthotics for pronation in a ski boot would be very effective to improve ski edge control, lessen transverse plane motion at the knees, and reduce foot fatigue. (If the foot is pronated in the ski boot, then one has to use their knees more in order to set the inside edge of the ski when turning). While a “three-quarter length” orthotic from a shoe may work in a ski boot, often the interior of a ski boot heel area fits narrower than a shoe, and so there may be trouble fitting the orthotic to the back of the boot.
I suggest ordering a narrow grind to the orthotics with shallow heel cups and a vinyl cover with Poron or Lunasoft to the toes. Sending the lab a tracing of the ski boot insoles would be helpful— or better still, the insole itself. A rigid cavus foot type with an orthotic in a ski boot can be problematic because of the dorsal midtarsal area pressure from ski boot buckles — and most skiers with this foot type have to find a boot that will accommodate their foot type.
Lloyd Nesbitt, DPM, Toronto, Canada
01/06/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Connie Lee Bills, DPM, John Rosselli CPed and Robert S. Schwartz CPed
I have adjusted orthotics for ski boots several times. It’s a much narrower shank and you have to grind the shell quite narrow. I use a functional sports-type orthotic with rearfoot intrinsic post to minimize bulk... 2 mm thickness forefoot extension.
Connie Lee Bills, DPM, Mount Pleasant, MI
Orthotics are essential! Shell selection is essential. Liners are less so, but our Surefoot custom liners are now so good, they double the life of a boot, and perform better (we use a patented memory foam that grips as tightly as the older foams, but have an elasticity that allows superior biomechanics). They are wired for heat, and pair with your phone. An orthotic that doesn’t fit in the footwear of its intended use will always be problematic, even if it’s otherwise perfectly designed.
John Rosselli CPed, Surefoot NYC, Robert S. Schwartz CPed, Eneslow
01/05/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1B
From: Paul Betschart, DPM
I have been a skier for many years and have used custom and non-custom orthotics in my ski boots as well as have had them made for my patients. Since the feet are locked in the boot and there is no heel to toe motion, a thinner shell can be used. Extrinsic posting is rarely needed. Devices need to fit the contour of the bottom of the boot to sit properly. Send the original foot bed or at least a tracing to the lab with the prescription to get the correct shell width. Top cover choice is based on preference. Vinyl is the most durable and water resistant but many skiers want to "stick" to their boot for better control. A semi-rigid closed cell foam can be used in these situations.
Balancing for forefoot pathologies with relief pads, metatarsal pads, etc. can be helpful as proper skiing technique increases load on the forefoot. Patients with marked equinus may need a small heel lift to allow for proper forward lean. Don't ignore the boots themselves. Most ski boots have the ability to be adjusted in both forward lean and cant (varus/valgus). A good boot fitter should be able to make those adjustments as needed. I have used these principles to get orthotics to fit for other low volume footwear such as ice skates, racing flats, soccer cleats, etc.
Paul Betschart, DPM, Danbury, CT
01/05/2023
RESPONSES/COMMENTS (CLINICAL) - PART 1A
From: Kevin B. Rosenbloom, C.Ped
Regardless of the type of skier, of type of skiing, a custom orthotic or insole that fits the shape of the plantar aspect of the foot in a neutral position will improve the comfort and performance. From your orthotic lab, you will need to request a narrow or ski-specific orthotic to fit into ski boots, a heel cup that is approximately 10mm (12mm for mens boot size 11 or larger) and a top cover that allows the foot to slide in and out easily for recreational skiers, i.e. vinyl or Protex. For advanced skiers, an EVA or Prolite top cover is recommended for better connection and less slipping within the boot.
Similar modifications can be made in the rearfoot, such as skives or rearfoot posts to help maintain the subtalar joint near neutral. The midfoot or arch of the orthotic should be full contact with the midtarsal joint in neutral. The forefoot of the orthotic generally does not require such things as met pads or off-loading pads because there are no propulsive or dorsiflexion moments loaded on the forefoot tissues. If a patient has forefoot modifications, I recommend foregoing them in a ski boot unless chronic pathology is present.
The modification pads often take up needed room within the toebox. Consider the boot shop that sold the patient the boots. If it has a reputable boot fitter, the patient will have had some custom insoles or OTS insoles provided by the boot fitter. Some are good and some less effective than a neutral impression that can be taken in your office and fabricated by your lab. If you can, send the boot liners or boots to your orthotic laboratory so the lab can fit the orthotic to the boot to make your life easier dispensing to your patient.
Kevin B. Rosenbloom, C.Ped, CEO, KevinRoot Medical
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