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12/03/2020
RESPONSES/COMMENTS (CLINICAL)
From: Kenneth Meisler, DPM
I have treated many immunocompromised patients with veruccae. Some of the patients get to me after having seen many doctors over a course of years. I treat all veruccae the same way, with a pulsed dye laser. I inform patients that it may take many more treatments than for a patient who is not immunocompromised. Those who do not respond to the pulsed dye laser are treated with Swift Microwave. Most patients respond eventually. Some lesions totally resolve and some get significantly better.
Kenneth Meisler, 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 2B
From: Robert Kornfeld, DPM
I have spent more than 30 years treating chronic foot and ankle pain and have had many cases of “recalcitrant” PT tendinitis. Once you come out of the “next best treatment” mentality and focus on the patient, you will find answers. Functional medicine teaches you to examine the patient's total health landscape to uncover immune burdens and any epigenetic and genetic issues (SNPs) which will create inefficiency in repair pathways. These underlying mechanisms are managed prior to any treatment. Once you have up-leveled immune function, you can heal these chronic cases via regenerative medicine injection therapies. This is how every doctor should be practicing. I have loved my practice all these years.
Robert Kornfeld, DPM, NY, NY
03/13/2024
RESPONSES/COMMENTS (CLINICAL) - PART 2A
From: Jeff Root
Regarding the query about the treatment of recalcitrant "posterior tibial tendonitis", or what many would call posterior tibial tendon dysfunction (PTTD), I would like to share a few of my thoughts. The PM News subscriber stated that the patient wears "HOKA shoes and custom orthotics". The term "custom orthotics" simply implies that the devices were not prefabricated. In some cases, the lines between custom and prefabricated shoe inserts have been intentionally and unintentionally blurred. In addition, the term "custom orthotics" tells us little to nothing about the nature (i.e. design and properties) of the orthoses because there are hundreds if not thousands of types of custom orthotics and orthotic designs.
For example, what was the position of the joints of the foot, including the STJ, MTJ and 1st ray when the foot was casted or scanned? What were the specifications of the orthotic prescription? What lab techniques were used in creating...
Editor's note: Jeff Root's extended-length letter can be read here.
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 2
From: H. David Gottlieb, DPM
Yes, Dr. Sullivan, prolotherapy has been around and used by podiatrists for a long time. My uncle started his podiatry practice in 1934 and my father joined him in 1943. They used prolotherapy using sodium moruate and/or alcohol, I believe. They were no longer using it when I joined them in 1982 but it was presented to me in a positive light. It seemed to me at the time that uncle was more focused on palliative care and orthotics and my Dad on office-based 'open' surgery.
I never learned the technique but believe that it has a place in ligamentous and other soft tissue conditions.
H. David Gottlieb, DPM, Baltimore, MD
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 2
From: Steven Belanger, DPM
Not everyone has the ability to have a concierge practice or a holistic practice that does not participate in any insurance plans. The reason for this is very simple. If someone practices in a relatively low income area, a doctor would go broke offering this type of service, as no one has the ability to pay for these services no matter how great or wonderful they are. So not everyone can just do this.
Steven Belanger, DPM, Fall River, MA
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
06/27/2023
RESPONSES/COMMENTS (CLINICAL)
From: Robert Kornfeld, DPM
Dr. Silver, I have been doing all kinds of regenerative therapy injections as an adjunct to a functional medicine work-up. I left insurance dependency 23 years ago. We all can do it.
Robert Kornfeld, DPM, NY, NY
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.
06/21/2023
RESPONSES/COMMENTS (CLINICAL) -PART 1B
From: Glen N Robison, DPM
Elliot Udell, I have followed your comments on this platform for many years, and for this one, I cannot stay silent on prolotherapy. The doctor who started the discussion was asking advice for treating interdigital neuromas and the proper dosage of the % medium used. Here is my experience with prolotherapy:
I have been using prolotherapy for over 10 years, stabilizing ankles, repairing torn plantar fascia, tendon and plantar plate tears, and even neuromas. When given in the right dosage, the right way to inject and absolutely no anti-Inflammatories such as Advil or ibuprofen or aspirin and say in the ankle, when it is set properly, it is very effective. I was trained by...
Editor's note: Dr. Robison's extended-length letter can be read here.
06/21/2023
RESPONSES/COMMENTS (CLINICAL) -PART 1A
From: Bret Ribotsky, DPM
Bob - with all your experience (Years ago, I even attended your class on this topic) and your very good results, I’ll ask, as I did a few years ago, to please publish your outcomes. I think that without peer-reviewed literature, medicine must be very skeptical of unsubstantiated treatments.
Bret Ribotsky, DPM, Fort Lauderdale, FL
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
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