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From: Peter J. Bregman, DPM


I have heard anecdotal information about this treatment for many years, very similar to how you described it. In fact there will be an article coming out shortly where I am on the opposite of the side of sclerosing injections. The reason being is if you read the literature, it takes a minimum of 20% alcohol to effectively cause chemical destruction of the nerve. So while I understand that there is a success rate for your injections, I would proffer that it is not the alcohol that is responsible for the success rate but it is the anesthetic itself. 


I venture to say if you switched out the alcohol with 4 mg of Decadron, you might even get better results not having to do so many injections. It is conceivable that somehow the alcohol has some sort of chemical physiological effect that enhances the anesthetic or vice versa but I think it’s more likely than not that it’s just the anesthetic that’s doing the job. There needs to be a study done using saline, local anesthetic, local anesthetic with 4% alcohol, and local anesthetic with 4 mg of Decadron. This would answer the questions above.


I also think that the patients that you think were cured by your 7 to 10 injections probably went somewhere else for different treatment. This is likely about the same number who had a neurectomy and did not do well and went somewhere else, which caused the surgeon to believe it was a success.


Peter J. Bregman, DPM, Las Vegas, NV

Other messages in this thread:



From: Ivar E. Roth, DPM, MPH


Going barefoot at home is a bad idea. Sooner or later you’re going to suffer an injury due to that recommendation. I guess the older you get, the wiser. While going barefoot might sound like a great idea, experience has shown me that it is not. Additionally, the more often you support your feet, the better your feet will function with the extra benefit of less injuries and accidents.


Ivar E. Roth, DPM, MPH, Newport Beach, CA



From: Allen Jacobs, DPM


The suggestion that hyperbaric oxygen is the “nectar of the gods” is incredulous. The retrospective studies examining the utilization of HBO for the management of DFU are at best controversial. The largest published retrospective studies demonstrate no benefit to system HBO, and no benefit whatsoever to topical HBO. Such studies have demonstrated no reduction in amputation rates, or advantage of HBO to comprehensive wound care.


The International Working Group on the Diabetic Foot's most recent recommendations stated that the indications for systemic HBO were “weak”, and for topical HBO non-existent. HBO therapy is never performed in a vacuum, and is...


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



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: 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:  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: 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: 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: David Secord, DPM


As Dr. Kiel is commonly using sclerosing injections on patients, I’m curious as to what code he is using and what solution he is using for “sclerosing” a nerve (Sclerodex, polidocanol, sodium tetradecyl sulfate [sotradecol] or phenol). I have to assume that it is one of these agents, as these are actual sclerosing agents, whereas 4% absolute alcohol is not (as evidenced by the fact that you are doing more than one injection). Clearly, if you have “sclerosed” the nerve, you don’t have to do it multiple times. 


David Secord, DPM, McAllen, TX



From: Ivar E. Roth, DPM, MPH


I have to agree wholeheartedly with Dr. Bregman concerning neuroma surgery. RARELY does there exist a reason to do a neurectomy. It has been at least ten years since I have removed a neuroma surgically. Between steroid, alcohol injections, and orthotics, rarely is anything else necessary. However, recently I had one very stubborn case and I did a release only, with full success. 


Just like it is now accepted that we only do a fascial release for heel spurs, meaning we no longer remove the bone, the same situation exists with neuromas; they just do NOT need to be removed. The standard of care should be NON-removal for us and for the benefit of the patient. That should be a point of distinction between DPMs and the MDs.


Ivar E. Roth, DPM, MPH, Newport Beach, CA



From: Kevin A. Kirby, DPM


Dr. Pinker is quoted in an interview (Editor's note: Dr. Pinker was misqouted; see previous note above) that being barefoot "improves awareness of their (child's) body in space", provides "better foot mechanics", causes "improved mechanics of the hips, knees, and body core", allows "stronger leg muscles, supporting the lower back region." Unfortunately, not a single one of his claims have any research evidence to support them.


Dr. Pinker's unusual claims are basically the same ones that Vibram FiveFingers made about their shoes in their advertisements for their shoes back in 2010 and later. Since Vibram had no research support for their claims, and injuries from wearing their shoes were starting to get out of control, they settled their class-action suit out of court in 2014 for $3.75m for the false and...


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



From: Keith L. Gurnick, DPM


I am continuing to see patients with acute bone and joint symptoms in their feet and ankles and other soft tissue injuries as a direct result of overuse stress that I believe is exacerbated by wearing structurally insufficient athletic exercise shoes. It is true that during the COVID-19 pandemic many of these patients have increased their exercise activities, and some have even gained some weight.


Many are walking more often and also walking further distances than before, or running for longer periods of time and on varying surfaces, or exercising more regularly because they have more free time. But one thing in common is that...


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



From: Robert Scott Steinberg, DPM


Thirteen subjects on a treadmill, a study does not make. 


We have all heard Dr. McClanahan's opinions on barefoot and minimalist shoes over the years. That craze has mostly gone. If all of this is new to you, to clear up any confusion, just read Kevin A. Kirby DPM's multiple in-depth articles on the subject. Dr. Kirby's work has been published in multiple scientific journals. He has also posted a great many articles on his Facebook page. I like Dr. Kirby because he does not pull his punches. He has plenty of research to back up the science.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Leonard A. Levy, DPM, MPH


Tilden Sokoloff, DPM, MD, described the historical relationship that Touro University has had with podiatric medical education. Touro University California was the brainchild of Dr. Bernard Lander, founder and first president of Touro College and University System. A team of four or five professors, led by Dean and Provost Bernard Zeliger, DO, started the first class. The program began 23 years ago on August 18, 1997 at the California College of Podiatric Medicine (CCPM) in San Francisco, with osteopathic medical students sharing with podiatric medical students the CCPM basic science curriculum, faculty, space, and other resources. 


The Commission on Osteopathic College Accreditation (COCA) which accredits U.S. osteopathic medical schools conducted the initial accreditation evaluation of the CCPM-based Touro University osteopathic medical school. As a result, the basic science component of CCPM which also provided the basic science curriculum for Touro, was granted its initial accreditation by COCA. Dr. Lander named me president of CCPM, an Honorary Founder of the new osteopathic medical school. Touro ultimately moved to its current space north of San Francisco on Mare Island. The New York College of Podiatric Medicine takes this initial experience to the next level.


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL



From: Robert S. Schwartz, CPed


Shoe surgery before foot surgery! I’m a lifelong Haglund’s sufferer, with supinator tendencies (cavo-varus, with plantarflexed first ray on right foot). I am lefty dominant, with shorter left side LLD (<1”). I played competitive sports until 65 and found viable footwear options. The first recommendation is longer shoe size. It makes a big difference. Double socks help reduce shear forces.


Haglund's wear pattern in shoe


The excessive wear pattern of the posterior-lateral inside counter of the shoe is easy to see. Shoe-surgery consists of cutting a 1” hole in the heel counter centered at the point of maximum tenderness. The space can be left open or stretch Spandex material inserted. When not in closed-back footwear, open-back clogs provide desired relief.


Robert S. Schwartz, CPed, NY, NY



From: Elliot Udell, DPM


Dr. Feinberg's example of how he met a woman at a party who was happier with orthotics made by her chiropractor than the set made by a podiatrist, opens the door to a deeper discussion. Should we deal with any orthotic lab that is owned by podiatrists, and is actively marketing their orthotics and training to chiropractors, physical therapists, and other non-podiatric professionals?


This hit home for me when a local chiropractor called me and asked me if she should use a certain orthotic lab that is heavily marketing itself to chiropractors. This lab is also present at our podiatry conferences and markets heavily to our profession.


Elliot Udell, DPM, Hicksville, NY



From: Janet McCormick, MS


In answer to Dr. Beaton's comment, "We have already lost general foot care to pedicurists because of inaction by our profession to prevent practicing podiatry without a license." In no way have podiatrists lost general foot care to pedicurists, and many podiatrists disagree with you and are hiring advanced trained pedicurists to allow them expansion of their incomes.


A medical nail technician (MNT) is NOT trained in general foot care and is not allowed in any state to perform it. They are licensed, however, to trim nails, reduce girth, and moisturize the feet on HEALTHY and controlled patients so that the podiatrists can perform...


Editor's note: Janet McCormick's extended-length letter can be read here.



From: John Moglia, DPM


With a CRN wife and a DPM/ RN degree for himself, I wonder if Dr. Busman would advise his children to pursue a DPM degree. It seems a CRN degree is a shorter career pathway with a wider scope of practice and a generous median income.


John Moglia, DPM, Berkeley Hts., NJ



From: Paul Busman DPM, RN


Dr. Musser wrote, "So I do feel bad for the physicians who were let go and replaced by CNPs. I feel this is a 'slap in the face' for both the highly trained physicians and a compromise on patient care for the sake of helping the bottom line."


This attitude is a slap in the face of nurse practitioners, who by and large are dedicated, well-trained, and excellent healthcare providers who provide first rate care to their patients with no "compromise in patient care." In addition to intensive medical training, what they bring to the table from their nursing background is...


Disclosure: I have a dog in this fight, as my wife is a CNP currently working in addiction medicine and pain management.


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



From: W. David Herbert DPM, JD


As far as NPs or even PAs functioning as primary care providers, I have no problem with it as long as these people are held to the legal standard that any primary care physician would be held to. That is, if they are going to function as doctors, they should be treated like doctors when they provide sub-standard care.


W. David Herbert DPM, JD, Billings, MT



From: Don Peacock, DPM, MS


Dr. Udell, I appreciate your response and I agree with you 100%. I also totally agree with Dr. Jacobs’ take. MIS surgeons cannot scientifically state that there is less swelling and lower infection rates with MIS HAV correction compared to traditional surgery. We can only state that MIS HAV correction with screw fixation yields better early VAS scores than open Scarf/Akin. For MIS HAV correction, we have scientific backing for the Reverdin-Isham, SERI, Bosch, Magnan, and the MICA/PECA. None of these procedures have established dominance over any other HAV surgery.


Some MIS procedures actually have significant pain and swelling after surgery. The non-fixated PMOs that MIS surgeons do for IPK and ulcers have significant swelling and dorsal pain for up to three months post-op compared to...


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



From: Allen Jacobs, DPM


Thank you, Dr. Peacock, for your interesting references to MIS surgery for the correction of bunion deformity. However, the published statement by the author clearly fails to support the claim that MIS surgery is associated with less swelling, less pain, and a lower infection rate. The references you cite do not substantiate that claim.


The preferred practice guidelines published by the Academy of Ambulatory Foot and Ankle Surgeons contains references in the chapter on “MIS correction of Hallux Valgus”. Of the 54 references, over 50% are taken from literature on...


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



From: Paul Busman, DPM, RN


I'd always worry about a patient who wanted an asymptomatic bunion surgically corrected strictly for cosmetic purposes. A person who was so concerned with appearance might well be dissatisfied with a correction which, while technically excellent, might not accord with their preconceived notion of what a perfect foot "should" look like. Despite perfect surgical technique, the patient might be left with a scar that they'd consider unsightly, a slightly shortened hallux, etc. No thanks! 


Paul Busman, DPM, RN, Frederick, MD



From: Elliot Udell, DPM


When I entered practice, over 35 years ago, I had two offices. One was in a suburban area in Long Island and the other was in a specific Chassidic community in Brooklyn. I found the patients’ reaction to bunions, hammertoes, and other foot deformities to be radically different in each community. I found that on Long Island, if a forefoot deformity was slightly painful or deemed "ugly", most but not all of my patients were more inclined to seek surgical corrections. In Brooklyn, where religious life and raising large families consumed family members from dawn to dusk, unless the deformity was extremely painful to the point of being incapacitating, or interfered with other aspects of their life, most but not all of my patients optioned for conservative management of their deformities.


Elliot Udell, DPM, Hicksville, NY



From: Earl R. Horowitz, DPM


The role of podiatric services must be fully developed and recognized in preventing falls in the senior population. Seniors fall only when their foot leaves the ground improperly during the gait cycle. Multiple and common foot problems that cause pain lead to abnormal sway action that causes senior to fall. Biomechanical dysfunction, arthritic changes, and loss of sensation may easily lead to sway and gait changes that cause falling. Senior foot and ankle problems may not seem significant in importance even to the senior themselves only because they do not realize the significance of the foot to controlling falling.


Foot and ankle pathology should be classified as one of the main causes for senior falls. Most podiatrists treat senior foot complaints not understanding their potential role of preventing seniors from falling that a full foot and ankle examination would indicate. Podiatrists must become more knowledgeable in examining gait and sway problems that lead to falls in seniors. They must develop examination, treatment, and preventive protocols for this life-threatening problem. Foot and ankle problems can change from year to year very quickly as seniors grow older. A yearly full foot and ankle examination should become a part of senior health plans. The opportunity for podiatry to be in the forefront in geriatric medicine and fall prevention is now!


Earl R. Horowitz, DPM, Jacksonville, FL



From: Donald Peacock, DPM


The debate over whether minimally invasive bunion surgery is better than traditional surgery for correction of HAV is currently being answered by comparative studies. A notable study was published in 2017 by Moses, et al. (Foot and Ankle International in 2017, volume 38 (8) pages 838 through 846). This comparative level II study showed no difference statistically between minimally invasive bunion surgery and a traditional procedure. My own experience with minimally invasive surgery has shown the same results. Prior to performing minimally invasive bunion surgery, I had personally performed over 1,000 traditional bunion surgeries and was board-certified by the American Board of Foot and Ankle Surgery. 


Pre- and Post-op X-rays of MIS Bunionectomy


From 2009, I have performed numerous percutaneous bunion surgeries. I have seen no difference in the outcomes between MIS and traditional bunion surgery. Above is a typical MIS bunion result showing x-rays, weight-bearing pre-op, and post-op 6 weeks of a MIS Austin and Akin. We performed a frontal plane correction with the Akin to achieve the improved sesamoid position.


Donald Peacock, DPM, Whiteville, NC

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