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From: Keith L. Gurnick, DPM


It may be that Dr. Paul Greenberg was misquoted, because making generalized statements about the after-effects of toenail avulsions and toenail matrixectomies such as, “It doesn't require any bed rest, and patients can usually do whatever activity they want by the day after the procedure” is inappropriate and not honest for many of our patients. Each patient should have specific after surgery orders and instructions and necessary restrictions or modifications depending on their specific needs and requirements.


Our patients need to be informed in advance that there are potential risks and complications, and also that there is expected disability and recovery time after toenail avulsions and matrixectomies, just like all the other procedures and surgeries that we perform. Even simple and routine procedures can inflict short-term pain and require some time for healing. In some patients, the necessary post-operative recovery does include rest, activity, and shoe modification and could also require time off work or time away from participation in sports activities as well. It just depends on the individual needs and issues of each patient.


Understating the potential post-operative effects of toenail surgery will set you up for an unhappy patient and the possibility of delayed healing, infections, and further disability. We owe it to our patients to be honest with them, and the same should be true when participating in radio or magazine or media interviews and on our websites as well.


Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:



From: Ivar E. Roth, DPM, MPH


Todd Sommer, DO, DPM, congratulations on your position at the wound center. You make podiatry proud.


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



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: Robert Kornfeld, DPM


Kudos to Dr. Mitchell for discussing foods that not only can cause gout attacks (which we all know), but foods that can ward it off. The healing effects of food (and likewise the pathology inducing effects of poor diet) are not applied enough clinically in our profession. Epigenetic assessment is critical in so many conditions and simply treating symptoms alone does not improve the overall health of our patients.


Robert Kornfeld, DPM, NY, NY



From: Ivar E. Roth, DPM, MPH 


According to Dr. Glenn Davison, with early intervention, it is possible to avoid bunions. That means obtaining proper foot support with the best shoes for bunions.


I hope Dr. Davison was misquoted concerning that the wearing of shoes with proper foot support will possibly avoid bunions with early intervention. This statement is not true at all and just perpetuates a myth that should be eradicated from being reinforced in the media, especially by our profession.


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



From: Robert D Teitelbaum, DPM


I too, have a very low recurrence rate from P&A procedures because I saw the problem early on in my career. A side nail matrix to me brings up the following image: sticking an index finger into a cup of pudding, then quickly retracting it. What do you have? A hole with the matrix extending in all directions up from the floor of the indentation. With the thinned out cotton tipped applicator soaked in phenol, I apply firm pressure in a centripetal fashion to soak all sides, including the invisible dorsal side of the matrix.


Twenty seconds from the finish, I do this again. With this, I get minimal 'residual nail spurs' 6 months post-procedure. In addition, what is very important is to explore the evacuated space with a curette after using the anvil nail splitter. Many times, I have pulled out a small piece of matrix that would be left without this inspection.


Robert D Teitelbaum, DPM, Naples, FL  



From: Ivar E. Roth DPM, MPH


I read Dr. McLean’s comment that regrowth after a P&A is common, which I do not agree with. I have been doing and following up these procedures for 36 years in practice. I know my recurrence rate is less than 1% as I tell all patients that I guarantee my work and will re-do any nail that they have ANY regrowth with for NO charge. I will say that meticulous removal of all matrix and careful use of phenol is important for great results. I am curious what the average practitioner's regrowth rate is but I doubt it falls into being able to say that it is common.


I will make a video of my technique to share with the profession via PM News soon to show the pearls of doing a P&A that does not result in regrowths.


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



From: Craig McLaws, DPM


Several of the comments about the article on the break-in at Dr. Morris Stribling's office in Texas seemed to imply he was at fault and had done something wrong. Dr. Silver wrote, “why does he carry opioids in his office and how much is he prescribing to his patients?” I know Dr. Stribling and he is a fine man, businessman, and DPM. As well as having a podiatry office, he owns a licensed pharmacy in the same building as his office. If you look up the original article at, you will see the surveillance video of the criminal stealing from the pharmacy, not from Dr. Morris’ podiatry office.


Dr. Finer questioned the handling of the medications. A quote from Dr. Stribling in the original KSAT article states, “Some of them were controlled substances, but none of them were level one or two because we keep those locked away.” I have no doubt Dr. Stribling and his pharmacy follow all rules and regulations for storage and handling of their inventory. Podiatrists once again want to eat their young. Don’t attack a colleague because he was the victim of a crime by a criminal.


These colleagues ought to reach out and apologize for questioning the integrity of Dr. Stribling because of their lack of knowledge. We all ought to search out the whole story before we pen outrageous statements about one another.


Craig McLaws, DPM, Billings, MT



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: Kathleen Neuhoff, DPM


I agree that with Dr. Bregman. Tarsal tunnel is a clinical diagnosis. Frequently, EMG nerve conduction studies and CTs are all negative. A very good ultrasonographer can find enlargement of the tarsal nerve but few in our area are capable of this. In addition, it is my feeling that we are seeing more of this than in the past. I believe this is also true of carpal tunnel. The explanation for the carpal tunnel increase was the increase in use of keyboarding, but it certainly does not apply to tarsal tunnel.


I agree that it is a diagnosis that is frequently missed, but I have always looked for it in my practice and I believe the incidence is increasing. Patients usually present with a diagnosis by another physician or Dr. Google that they have planter fasciitis which has not responded to conservative care. However, their history generally includes an increase in pain as the day goes on, and pain when they are not standing on their feet. Tarsal tunnel is painful on palpation of the medial and lateral calcaneus and the tarsal tunnel trigger point. Sometimes, they have concurrent plantar fasciitis which makes treatment a bit challenging. Unfortunately, some have had plantar fascial releases which have not helped their pain at all. Are others seeing an increase in this diagnosis?


Kathleen Neuhoff, DPM, South Bend, IN



From: W. David Herbert DPM, JD


According to the BLS, nurse anesthetists make more than pediatricians and dentists also. Because I flew in the military in the late '60s and early '70s, I knew a number of people who retired as airline pilots a number of years ago. The airline pilots I knew did not engage in any activities that I would consider as interesting as being a podiatric physician. 


I would also like to know if the average incomes of podiatrists included the incomes of those in residencies or fellowship programs. There are a lot more things to consider when choosing your lifetime career than simply an average salary published by a governmental agency.


W. David Herbert DPM, JD, Billings, MT



From: Burton J. Katzen, DPM


It was very disheartening to see that podiatrists ranked #22 in the latest BLS statistics of highest paying jobs. This is 16 spots behind the category of "all other doctors" and 10 spots behind nurse anesthetists, whose sole source of income depends on surgeons like us, but who have no overhead.


With many of the other income rankings ahead of us that don't require 8 years of post-college education with enormous educational costs, we must ask ourselves how are we going to attract the "best and the brightest" to pursue our wonderful and rewarding profession in the future.


Burton J. Katzen, DPM, Temple Hills MD



From: Peter J. Bregman, DPM


I read with some dismay that tarsal tunnel can be diagnosed with CT scan? I wish that there was further explanation of this as the only tarsal tunnel that can be diagnosed by CT scan is one in which there is a space occupying lesion and, in the case of CT scan, it would be boney, unless using a CT with superior soft tissue resolution. Also, neither MRI nor CT unless MRI neurography should be used to make the diagnosis, as it is a clinical diagnosis. Most cases are not caused by space occupying lesions, but a compression neuropathy related to both biomechanical and physiologic changes in the nerve or its surrounding anatomic tunnel(s).


Also of note, I have heard some physicians, especially neurologists, comment that this condition (tarsal tunnel) is rare. It is my opinion and the opinion of others that it is not rare at all and much more common than is thought. The problem is that it is often misdiagnosed or under diagnosed. I think part of this fallacy (rare) is the reliance on EMG/NCV studies that have a very high false negative rate. Many doctors rely on EMG to make the diagnosis. If the tech or physician is not skilled enough, tarsal tunnel will be missed or diagnosed as some kind of neuropathy.


Peter J. Bregman, DPM. Las Vegas, NV



From: Lawrence Rubin, DPM


I appreciate Dr. Miguel Cunha's post about what I like to call, "stories the patient's shoes can tell." I believe we should regularly be inspecting the wear pattern on the soles of our patients' shoes. I can vouch for the fact that podiatrists like myself who attended the podiatry colleges of the '50s and '60's learned how valuable that can be when assessing abnormalities of weight distribution during stance and gait. 


Lawrence Rubin, DPM, Las Vegas, NV



From: Ejiro Isiorho, DPM


I would like to commend Dr. Naomi Schmid! As a provider and a mother of young children, I am impressed with the balancing act that must be taking place! Congratulations Naomi, I and many others are pulling for your success.


Take care, stay safe, and be blessed!


Ejiro Isiorho, DPM, Tigard, OR



From: Alan Sherman, DPM


I am inspired by the story in the last issue about Naomi Schmid, DPM being selected as chief medical officer (CMO) of the 70 year old regional healthcare system (Lake Region Healthcare Leadership). This is one very accomplished podiatrist and I always take joy in seeing my colleagues testing the limit of where a DPM degree can take you. What a great example for the marketing programs of the colleges to use in their pursuit of more and better applicants.


Alan Sherman, DPM, Boca Raton, FL



From: Michael L. Brody, DPM


The Physician Fee Schedule Rule has been published and the news is not good. The net result is a decrease in payments of 3.89%. How does this break down? First, in 2021, Congress passed an act called the Consolidated Appropriations Act of 2021 that gave an increase of 3.75% to the Physician Fee Schedule. That act is set to expire at the end of 2021.


Second, due to the Balanced Budget Act, there will be a decrease of 0.14% in the Physician Fee Schedule. The net result is a decrease in fees of almost 4% from what we received in 2021. The good news is that the published document is the PROPOSED Physician Fee Schedule. All rules published start with a proposed rule. When it is a proposed rule, the rule is open for a public comment...


Editor's comment: Dr. Brody's extended-length letter can be read here.



From: Doug Richie, DPM


Dr. Udell suggests a boycott of foot orthotic labs that provide products to "non-podiatric" professionals. To that, I ask Dr. Udell if he avoids using products from any company which sells wound care technologies, surgical devices, medical supplies, and medical imaging devices to healthcare professionals other than DPMs? Ironically, the foot orthotic lab referenced in Dr. Udell's post apparently supports the podiatric profession by sponsoring lectures at our scientific conferences. Any foot orthotic laboratory which contributes to funding of continuing medical education for our profession should be lauded and not criticized in my opinion.  


Doug Richie, DPM, Long Beach, CA



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

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