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From: Dieter J Fellner, DPM


Ray McClanahan states that "intrinsic foot muscles get about 10% bigger/stronger when an individual wears minimal/natural (twistable) footwear." That may well be the case. I am left asking myself, where is the scientific evidence that such an event is protective against pathology? I have listened to his YouTube lecture before, with enormous interest and anticipation. Regrettably, I did not find the answers there. 


I will gladly read the papers cited by Dr. McClanahan if he can provide the citations that can put to rest my niggling concerns, could it be there is no scientific evidence that a slight gain in intrinsic muscle mass can protect the foot from the development of plantar fasciitis or hallux valgus? And I will look forward, with enormous interest, to the scientific evidence that his correct-toes device and floppy shoes can provide the answers to the problems, as he suggests. My clinical experience with patients has been diametrically opposed to that of McClanahan. Many of those patients arrive already wearing those flippy floppy shoes together with painful deformity, plantar fasciitis, etc. 


I will even settle for a few anecdotal reports from his many patients to corroborate the idea that a hallux valgus deformity is reversible. After his 17 years in practice, there must be many such patients!


Dieter J Fellner, DPM, Yuma, AZ

Other messages in this thread:



From: Jay Kerner, DPM


Suggesting an anti-inflammatory diet to patients with gout, inflammatory arthritis, diabetes, etc. is good medicine. Suggesting cherry juice, turmeric, bananas, watercress, and low fat milk products as gout preventatives is, however, in the realm of alternative medicine. Though there have been individual studies suggesting the effectiveness of cherry juice as a gout preventive, there are recent studies that show it has no effect. There are papers now questioning the role of purines in initiating gouty attacks.


There are no studies for these foods for any pathology with the strength of the vitamin D3 or anti-inflammatory diet studies. Advising patients to take them based on ‘recent studies’ is more a belief or exaggeration than evidence-based medicine...regardless of ‘epigenetic factors’. 


Jay Kerner, DPM, Rockville Centre, NY



From: David S Wolf, DPM


Kudos to Dr. Ivar Roth for his innovated treatment for both humans and dogs. What a positive marketing opportunity for our profession to educate the population of what a podiatrist aspires to.


David S Wolf, DPM (Retired)



From: Herbert Abbott, DPM


Dr. Gurnick, having performed tens of thousands of these procedures over the span of a 30 plus years career, and having performed them on both of my own two great digits as well, I must say that Dr. Greenberg is SPOT ON! I am quite sure that he does a thorough informed consent as well, and the patient is aware of all risks, benefits, and alternatives. His wording is “usually,” and he is absolutely correct - any of my colleagues would agree. As for your results, I cannot comment other than maybe you are not doing the procedures correctly?


Herbert F. Abbott, DPM, New York, NY



From: Tom Silver, DPM, Steven Finer, DPM


I was disturbed to read the article about Dr. Morris Stribling getting $1,000 of opioids stolen from his office and, as a result, he has added a physical security team on his property and urges others to lock up all controlled substances. I see no reason why any podiatrist should have opioids available in their clinic. You are just asking to be robbed at gunpoint or have your office broken into if patients that are seeking drugs know that you have them.  


When narcotics are needed, they should only be prescribed through a pharmacy and on a very limited basis. The bigger question I would ask this doctor is why does he carry opioids in his office and how much is he prescribing to his patients?  


Tom Silver, DPM, Minneapolis, MN


The storage policy for drugs may vary from state to state. However, it is expected that drugs should be stored in a safe and that there is a dispensing legend. The legend should show patient name, name of drug, and number of pills dispensed. Personally, why take the risk? If needed, write a prescription. The break-in may have been avoided as who knows what is stored in that office. 


Steven Finer, DPM, Philadelphia, PA



From: Elliot Udell, DPM


Dr. Rotwein asks the question as to whether podiatrists should teach non-podiatrists how to cast for orthotics. There is a bigger "elephant siting in the room." What we should really be asking is whether any of us have any problems doing business with certain orthotic labs that spend a lot of time, money, and effort teaching and marketing orthotics to chiropractors, physical therapists, and other non-podiatric healthcare professionals?


This issue came to my attention last year when a local chiropractor called me and asked for my opinion on whether she should take training and utilize a certain orthotic lab to make foot orthotics for her chiropractic patients. What was extremely bothersome is that same company advertises heavily to our profession and sponsors lectures at our seminars. 


Elliot Udell, DPM, Hicksville, NY



From: Irv Luftig, BSc, DPM


After 41+ years in practice, I've seen my share of colleagues, myself included, teaching podiatry students/residents/younger podiatrists the finer points of what makes our profession so specialized and necessary. Dr. Abe Plon took me under his wing and set me on a wonderful path back when I was a student in the 1970s and again after I started practicing in the early 1980s.


I've never had an orthopedic surgeon I work with show me how to do a hip, or a total knee or shoulder replacement. I've never had a nuclear cardiologist show me how to catheterize a heart. That would be a ludicrous expectation. Why are podiatrists like Dr. Overstreet teaching practitioners who never stepped inside a podiatry classroom to take our places. It makes no sense.


Irv Luftig, BSc, DPM, Hamilton, ON, Canada



From: Keith L. Gurnick, DPM


It is not at all surprising that some general practitioners, nurse practitioners, and others would feel comfortable performing similar foot care that podiatrists routinely provide, after sitting in on a lecture or watching and learning from a podiatrist performing procedures such as a toenail trimming, callus debridement, ulcer and wound care, toenail avulsions, or even a matrixectomy or a fluid cyst aspiration. After all, we podiatrists, with our four-year podiatry education and three-year residencies, were all educated and trained to do these same procedures. What is alarming, however, is when they think they are clinically competent after the brief "SODOTO" (See one, do one and teach one) method of teaching and learning skills. The fact is, if you don't know what you are doing as a healthcare provider, you are going to cause some problems. And guess who will be called to bail out these non-specialists? Any and all of these routinely provided procedures have the potential for adverse risks, complications, and bad outcomes.


If others are going to do the procedures, they must be equally able to manage the patient afterwards, whether with good or bad outcomes. Non-podiatrists, those with extremely limited specialty specific education in the foot and ankle who perform these type of foot and ankle procedures, should never be held to a "lower standard" of care simply because they are not podiatrists.   


Keith L. Gurnick, DPM, Los Angeles, CA



From: Dennis Shavelson, DPM, CPed


Podiatry has forsaken evidence-based biomechanics, functional foot orthotics and their root causes that Dr. Root, et al. implanted into our profession in the 1970s. Subtalar joint neutral, pronation, hyperpronation and Root’s biomechanical examination are evidenced to be flawed and not useful to make biomechanical decisions. A 2017 study determined that “none of the deformities suggested by the Root method correlated with altered kinematics” and was “no longer valid for clinical practice.” 


In the past, shoemakers, arch support fabricators, physical therapists, orthopedic surgeons, chiropractors, and orthotic labs openly brought us up to biomechanical speed. But currently, the exciting drive to elevate podiatry to be on par with MDs and DOs has supplanted non-surgical bio-architecture and biomechanics in importance as an acculturation of the DPM.


I gave warning about the future of biomechanics in a 1989 article. Using a 3 degree varus heel wedge and “posting to cast” is no longer the standard of care when it comes to biomechanics and custom foot orthotics. Instead, we are fast becoming the standard of care of orthopedic foot surgery, wound care, and regenerative sports medicine as we continue to acculturate podiatry. Should other professions draw a line in the sand to prevent that from happening?


Dennis Shavelson, DPM, CPed, Tampa, FL



From: Jeff Root


Dr. Rotwein asks if you would teach a non-podiatrist how to cast for orthotics. I suggest that the answer to that question depends on who and why you might want to teach others to cast for orthotics. If the podiatrist is skilled at casting and is capable of training a non-podiatrist such as an office assistant to properly cast, then the answer might be yes. In this scenario, the podiatrist can personally evaluate the cast or scan of the foot and can prescribe an appropriate orthosis for their patient.


However, in my opinion it would be inappropriate to train a non-podiatrist to cast if that person was not qualified or was not working under the supervision of someone who is qualified to prescribe, dispense, and provide any necessary post-orthotic follow-up. Successful foot orthotic therapy requires both a quality cast or scan of the foot and an appropriate prescription that is specific to the individual patient’s condition and needs.


Jeff Root, President, KevinRoot Medical



From: Todd Rotwein, DPM, Lawrence Rubin, DPM


I would ask my esteemed colleagues, where exactly would you draw a line? Would you teach non-podiatrists how to cast for orthotics?


Todd Rotwein, DPM, Hempstead, NY


I agree with Dr. Markinson that podiatrists should not withhold information about podiatric approaches to patient care from other health professionals. Similarly, I find it very disturbing that some podiatrists openly tell me they will not provide preventive diabetic annual comprehensive foot exams, because wound care is their practice's "bread and butter." I realize that this opens up a whole can of worms regarding what is and what is not ethical professional conduct, but ignoring these realities helps no one.


Lawrence Rubin, DPM, Las Vegas, NV



From: Allen Jacobs, DPM


I read with interest the decision in the state of Pennsylvania that a podiatrist may act as supervisor for a CRNA. Based on my prior experience, I suggest that one approach this with caution as an example of being careful for what you wish for.


Some years ago, I acted as a defense expert in a wrongful death case. In this particular state, absent the physical presence of an anesthesiologist in the operating room, the “surgeon“ was responsible for the actions of the CRNA. In this particular case, the nurse anesthetist gave a medication by bolus which was contra-indicated. The podiatrist was busily performing an excision of a ganglionic cyst. Unfortunately, the patient expired.


In addition to suing the anesthesia group, the podiatrist was also held liable due to the fact that...


Editor's note: Dr. Jacobs' extended-length letter can be read here. 



From: Robert Scott Steinberg, DPM, Bryan C. Markinson, DPM


I think some of my colleagues are being quite naïve, or their egos have gotten the better of them! There was a time when DPMs owned orthotics. 


If you don't respect our specialty, find another profession.


Robert Scott Steinberg, DPM, Schaumburg, IL 


I need to point out some wrong conclusions by Dr. Ribotsky. Firstly, prior to coming to Mount Sinai, I ran a private solo community practice for 16 years, and taught anyone and everyone who asked anything they wanted to learn, believing in that ethic long before I came to Mount Sinai. It brought me more patients, never less. I do agree that academic center practice is different from community practice. Still, I cannot imagine ever that teaching a nurse practitioner or a PA coming back to hurt me by losing patient volume...and in his last statement, about nurse practitioners replacing us.


I know Bret for many years, and when he was actively practicing podiatry, I know for a fact that he never worried about that, as I do not. As the nurse practitioner or similar professionals get more and more into podiatric care, it has nothing to do whatsoever with what podiatrists are teaching them, but rather what practice enhancing opportunities exist that podiatrists continue to trivialize or downright ignore.


Bryan C. Markinson, DPM, NY, NY



From: Ben Pearl, DPM, Stephen Peslar, BSc, DCh


The medical world is a big interconnected ocean; even more so in the age of the Internet. My experiences have led me to the conclusion that teaching is noble, but it is best to know your environment. Know whether you are swimming with the dolphins or the sharks.


Ben Pearl, DPM, Arlington, TX


I worked in a publicly funded foot clinic with 2 other podiatrists. We provided hands-on training to nurses. It seemed to go well. When 2 podiatrists retired, applications for funding 2 positions were filed with management, while the podiatrist and 3 foot care nurses were still at the foot clinic. Then a budget cut occurred and the podiatrist was downsized. Now there are 3 foot care nurses at the foot clinic. They refer patients to their PCPs when a foot problem or lesion requires advanced treatment or examination or radiographs. In retrospect, perhaps if the podiatrists did not train the nurses, then 3 podiatrists would still be working at the foot clinic. 


Stephen Peslar, BSc, DCh, Toronto, Ontario, Canada



From: Alan Ng, DPM


Interesting post by Marc Jones, interesting how he takes one year to post for open payments. He doesn’t understand that investing in a company when they start up is a risk. That money sits for years hoping that it does well and we get lucky. Every other year, the amount made on that site was a fraction of what was made in 2019. Most of those payments were from speaking and teaching. While someone like Marc is sitting at home, those of us who work with industry are away from our families designing or teaching other physicians new techniques or better ways to perform surgery.


Alan Ng, DPM, Denver, CO



From: Kathleen Satterfield, DPM


I was surprised to hear my friend Bret Ribotsky’s take on educating other healthcare providers as to the ways of podiatric care. My experience has been the opposite. In the early 2000s, I wrote a BHPR grant that called for cross-training between family practice physicians and podiatric residents at UT Health Science Center in San Antonio and it was generously funded. Our residents learned how to recognize common health problems they could treat as did FP residents learn how to take care of basic foot problems and more importantly when to refer to us for more complicated care.


It had exactly the opposite effect than what Dr. Ribotsky said. The Podiatric Service got more referrals as did the FP department but both were more accurate and useful. Unfortunately I left UTHSCSA before I had an opportunity to write up the study results but anecdotally they were positive. An internist may know how to perform an ingrown nail avulsion but that does not necessarily mean they are prepared to do it, comfortable to do it, or even want to do it.


I respect my colleague Dr. Ribotsky very much but my experience does not mirror his. In my experience, if interprofessional education teaches my colleagues to do what I do, it may instead make them respect my skills and say “You are the expert here. Please go ahead and do what you do best.”


Kathleen Satterfield, DPM, Pomona, CA



RE: WA Podiatrist Trains Nurses in Medical Grade Footcare (Bryan Markinson, DPM)

From: Bret Ribotsky, DPM, Sheldon Nadal, DPM


Editor's note: Dr. Ribotsky's video response can be viewed by clicking here


I agree with Dr. Markinson’s point of view. I think that by sharing your knowledge with other medical professionals, you are more likely to gain a fan and more referrals than lose referrals.


Sheldon Nadal, DPM, Toronto, Canada



From: Marc Jones, DPM


Dr. Ng expressed his frustration in hospitals beginning the trend that was started by ASCs of making physicians use “cost-effective” implants. Why is he concerned with this? You don’t have to look any further than In 2019, Alan Ng made $661,755.13 from biomedical companies, including Paragon 28, Zimmer, and Wright among others. 83% of that money came from ownership or investment interest in the companies and another 13% in consulting fees. If this trend continues, he himself will stand to lose a lot of money if the expensive implants cease to be used in the hospital setting. It is hard to believe that he is concerned about patient outcomes.


Marc Jones, DPM, Spokane, WA



From: Randall Brower, DPM


This article about flip-flops does a huge disservice to our profession. There is absolutely no "good" flip-flop on planet earth! Flip-flops require the foot to over-flex the toes, engage the Achilles too early during gait, and lead to neuromas, hammertoes, foot cramping, and Achilles tendinitis along with PT tendinitis among other over-use syndromes. Marketing gimmicks like "fit-flops" or arch-support flip-flops are terrible for our feet. 


I thought I would be preaching to the choir, but I guess not in this case. It's frustrating that podiatrists have been suckered in to marketing gurus who couldn't care less about feet. There are no biomechanical reasons we should be advocating for flip-flop usage. We, as foot health specialists, should only advocate footgear that is healthy for our feet.  


Randall Brower, DPM, Avondale, AZ



From: Dennis Shavelson, DPM


Dr. Ellman, by leaving out underpinning, inherited biomechanical pathology as the number one trigger of foot pain, foot deformity, performance issues, and degenerative joint disease from his list, is missing a great public service opportunity to educate the public of the importance of lower extremity biomechanics.


If you are having foot pain living life on hard surfaces while comfortable living on carpet, that is pathognomonic of one's endogenous structural collapse in some part(s) of the foot that needs to be supported, stabilized, or balanced rather than be dampened.  


Cushioned shoes, shock absorbing surfaces, and reduced pounding lifestyles mask and defer the predicable bunions, pedal collapse, muscle engine atrophy, and back pains that develop over time in most of us that can be diagnosed, treated, compensated, and controlled using modern biomechanical technology.


Dennis Shavelson, DPM, Tampa, FL



From:  Patrick J Nunan, DPM


I want to add to Dr. Kominsky’s comments on cost. Many hospitals are contracted with maybe 2-3 suppliers of surgical hardware. Before getting approval, you have to submit a request and possibly present before a hospital committee on why and how the new equipment is better than what they have negotiated already with other companies. The new technology must be usable to most of the podiatrists and orthopedic surgeons on staff. It must be the same cost or less expensive than what is already on the shelf. The equipment needs to be unique and there is NO other way to fixate the procedure. The days of getting any equipment we want is over!  


Patrick J Nunan, DPM, Beaufort, SC



From: Don Peacock, DPM, MS


This post is of interest to me because I know both parties involved. I rotated through Dr. Kominsky’s program as a podiatry student. I was impressed by his surgical talent and his willingness to teach. Likewise, I know Thomas Bembynista, DPM and I met him at minimally invasive academy seminars. He is a superbly trained foot surgeon with stellar surgical skills. 


Like Dr. Kominsky, I shy away from claims of better when it comes to techniques. There are too many variables. One of these is who does the surgery. The post reminds me of one of the best foot surgeons I have ever known who practiced in NC for years. He did not have hospital privileges for most of his career. He performed large foot surgeries in the office under local with perfectly skilled outcomes. He often used K-wires for large rearfoot fusion cases performed under local anesthetic in his office. His name was Barry Johnson, DPM and his surgical skills were amazing. There was something almost magical with his abilities.


The truth is some surgeons are just good at what they do. Drs. Kominsky and Bembynista would fall in this category. Whatever technique they do, it's likely to have good results. It ain’t the car (technique), it’s the driver (surgeon).


Don Peacock, DPM, MS, Whiteville, NC



From: Burton J. Katzen, DPM


In response to Dr. Loshigian's post about there being no significant evidence that there is faster recovery time with minimally invasive surgery, I will agree that the long-term results of traditional vs. MIS might be the same depending on the procedure and surgeon. I assume what Dr. Loshigian calls “significant evidence” means evidence-based medicine. Unfortunately, it would be extremely difficult to satisfy surgeons who require level 1 or 2 evidence.


At level 1, you would have to have patients agree to have one foot performed traditionally and one foot using MIS techniques. At level 2, you would have to have patients sign up for surgery and randomly...


Editor's note: Dr. Katzen's extended-length letter can be read here.



From: Don Peacock DPM, MS


The comparative studies between traditional and MIS HAV corrections have shown some slight differences in VAS scores in the early recovery period. However, the VAS scores even out fairly quickly at 3 weeks or so. Trying to answer the question as to which is best is not easy to conclude. Scientifically, there seems to be no difference between the disciplines with respect to HAV correction.


I do believe the increased popularity of MIS HAV correction will continue and will be patient driven. People like small scars, especially in the case of percutaneous procedures. There is psychology involved here as well; similar to the well-known placebo effect. It is likely that percutaneous scars are going to be well received by the patient and better results reported because the wounds appear smaller. If it looks like less trauma is done, then it will be perceived as such.


These questions are just as much answered by psychological effects imparted by a perception of less invasive techniques. These effects cannot be understated. If the patient thinks it is less invasive, it probably will be perceived as such. The placebo effect is well documented in medicine and patients can even get better with sham surgery. We have only scratched the surface on understanding how we heal and how our patients perceive healing.


Don Peacock DPM, MS, Whiteville, NC



From: Lisa M. Schoene, DPM


Like Dr. Galluzzo, I have been performing 4% alcohol sclerosing injections for neuromas for about 12 years. I wish I had started using them earlier.  I too have also had fantastic success with the regimen of 7-10 injections. I have a large sports medicine practice and my patients are thrilled with the success as there is no downtime and no reduction in their athletic activities. There are few to no side-effects, so this is better than using corticosteroids. 


I utilize an outside ultrasonography doctor who works with many DPMs in the Chicago area. We have discussed that utilizing the 4% alcohol causes no damage to the fat pad (which is almost always too thin) nor to any of the surrounding muscles or other soft tissues. I have performed only 1-2 surgeries on neuromas since I have started using the solutions. I have also used this injection for injuries to the plantar proper digital nerve which gets caught under the sesamoid and can cause quite a bit of pain. This eliminates removing the medial sesamoid, which I prefer not to do.  


These solutions have been long utilized for bladder and cardiac procedures, so the dehydrated alcohol has been around for a very long time. Maybe it is time to do a multi-center/office study utilizing this treatment protocol as an alternative to surgery, especially with the limited availability of corticosteroids, so we can "prove" the success that we are already achieving. 


Lisa M. Schoene, DPM, Chicago, IL



From: Brian Kiel, DPM


Dr. Bregman, you are correct in your statement that it takes at least 20% alcohol to cause nerve destruction. The purpose of sclerosing, however, is to have an effect that is not destructive. I feel that there is a desensitization of the nerve rather than destruction. Of course I have no studies to prove it and I think that would be an excellent project. In the meantime, my patients respond and those who have developed neuroma pain in another area, several years later, return to my office as a result of successful treatment. 


Brian Kiel, DPM, Memphis, TN

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