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RE: Podiatrists and the Prevention  of Back Pain

From: Jeffrey Trantalis, DPM 


I feel we, as podiatrists, can have a big input in caring for the elderly in preventing the need for back surgery. The back surgeons may not be happy, but I do not care. This is for the betterment of outcomes. My whole life, I have worn orthotics with lift therapy for a pelvic rotation, allowing me to subsequently become a runner and lose 60 lbs. I have had the unique opportunity working for a back surgeon. After about 9-10 months, the orthopedic back surgeon came up to me asking what I was doing with his patients? After being puzzled by this, I responded, “I hope helping your patients.” Then he said, “Not the patients I wanted to do surgery on." 


Then I started realizing that as a podiatrist I had future many back patients walking into my podiatry office. I was helping so many elderly people with orthotics and biomechanics that I feel we are missing out on a population that we can save by eliminating debilitating back surgery. What I discovered is that you either have a limb length or pelvic rotation, or as you age, you develop one of these conditions. With heel lifts and custom orthotics, I was able to help a lot of people from needing back surgery.


Jeffrey Trantalis, DPM, Delray Beach, FL

Other messages in this thread:



From: Judd Davis, DPM


Dr. Dahlin (or any others who have successfully transitioned away from dealing with insurance companies), I was hoping you could expand on the pros/cons of going to the "direct care" model. Are there some websites or books that detail this process for specialists like us, instead of PCPs? 


When researching direct care, most of the links come up for primary care. I see many of the PCPs in my city going to concierge medicine. I also see a number of mutual patients of these PCPs stating they will not pay a monthly fee and switching to other docs that still take their insurance. I imagine it would be even more difficult to get podiatry patients that are seen irregularly for their foot/ankle conditions to agree to this kind of monthly fee arrangement. I think there are many of us that feel trapped by the huge insurance company's take it or leave it attitude and would love to escape that business model; we just don't know how.


Judd Davis, DPM, Colorado Springs, CO



From: Joey Dahlin, DPM


In response to the comments by Dr. Allen Jacobs regarding the commercialization of medicine, thank you for raising such pivotal questions that should certainly be asked. The concerning and conflicting answers to several of his questions were influential in motivating me to step away from insurance based medicine and develop a new option/system for patients. Direct care medicine has eliminated all middlemen and substantially reduced the restrictions and frustrations regarding patient care. For anyone looking to practice medicine in a different manner, in its truest sense, consider transitioning to a direct care model now.  


The 4% Medicare cut in 2023 and the continued changes with medicine, healthcare, and insurance companies will certainly only make it more challenging and unpleasant to maintain independence and practice podiatry independent of supergroups or hospitals. If you want to enjoy medicine again, provide better care, and get more time with your patients, now is the time to change. You will not regret it, if you truly love medicine and your patients.  


Joey Dahlin, DPM, Grand Junction, CO



RE: Politics and Healthcare

From: W. David Herbert DPM, JD 


I attended law school in Sacramento, California in the 1980s. My law school offered an elective course which allowed us to work with an attorney who was a lobbyist. One of the students in my class was an optometrist who was working with the optometrists' lobbyist. There was not an attorney lobbyist representing podiatry in the state legislature at that time. I decided to work with the attorney lobbyist representing the chiropractors. One of the issues at that time was whether a chiropractor could order an MRI at a hospital. Organized medicine was very much against this and and a former president of the California Medical Association (who was a retired radiologist) was flown up from Los Angeles to testify against it.


The assembly committee on health had a member who was also an optometrist and very much in support of the chiropractors' Bill. By being prepped by both the chiropractors and optometrists  lobbyists, he was able to effectively question the retired radiologist when he was testifying. Eventually, the Bill was passed and signed by the governor. Remember, even if you do not like politics, politics affects you personally and professionally every day!


W. David Herbert DPM, JD, Billings, MT



From: Pete Harvey, DPM, David Secord, DPM


Try Henry Schein for Polocaine 2%.


Pete Harvey, DPM, Wichita Falls TX


I switched to Ropivicaine and have had no problems with supply (so far).


David Secord, DPM, McAllen, TX



From: Robert Kornfeld, DPM


Kudos to Dr. Smit. As we age, it’s imperative to nurture your passions. I went back to music (my first love as well) and wrote and produced many songs. I’m currently in a fantastic blues band. We’re writing our own songs and doing covers as well. We recorded an album last year, and we play gigs around the Long Island and NYC area. I feel like a teenager again. 


Robert Kornfeld, DPM, NY, NY



From: Thomas Silver, DPM


I remember the wise words of an instructor who said, "when a patient has knee pain, our job is to determine if the pain is coming from the knee, above the knee, or below the knee. If it's coming from below the knee, then we can fix it; otherwise, refer them to the appropriate specialist who can fix it." I think the same goes for back pain. If it could be coming from the feet, then (hopefully) we can fix it. Over the years, I have found it to be a real bonus when I get patients into orthotics and they tell me that their knee, hip, and/or back pain went away too!


Thomas Silver, DPM, Golden Valley, MN



From: Elliot Udell, DPM


Thank you Dr. Oloff for shining a light on the commercialization of medicine. The example given was just the tip of the iceberg. Look at the commercials being advertised on television all day long. They advertise drugs for breast cancer, psoriasis, injections to control cholesterol, diabetes, etc. Some of these drugs may be very helpful, but many of them have side-effect profiles and only the patients' oncologist, rheumatologist, endocrinologist or dermatologist can determine if it is a right choice for a specific patient. 


I have a personal ax to grind. I am a breast cancer patient and there is one drug advertised all day long. They depict the people taking it as happy, family people going about normal lives with their children and grandchildren. I took the medication for three days and was ready to call 911 and the side-effects I endured were not rare but common to all who take the drug. In the original studies, a large percentage of people had to drop out because they could not tolerate the side-effects. 


Elliot Udell, DPM, Hicksville, NY 



From: Allen Jacobs, DPM


When corporations suggest that one utilize particular codes for reimbursement of goods or services from which they profit, research the appropriateness of such CPT or ICD-10 codes before utilizing them. Remember, the goal of industry is to increase product utilization and profit. The suggestion that topical application of 8% capsaicin qualifies as “destruction of a peripheral nerve” is dubious. We have all too much of code interpretation and manipulation in practice. Slant back nail removal without anesthesia billed as CPT 11730. Arthroereisis billed as “open reduction and internal fixation of a peritalar dislocation,” or “modified subtalar joint arthrodesis”. Radiofrequency coblation billed as “partial plantar fasciotomy”. Lapidus procedures with screw fixation extending into a cuneiform (s) billed as “intertarsal fusion”. 


Recently, one particular company manufacturing hardware for performance of the Lapidus procedure has suggested that with the utilization of their device, a modifier may be added indicating that the procedure should be paid at a higher level due to complexity. Our residents in St. Louis have been given sample operative reports (from a particular company) to dictate so as to justify appending the complexity modifier to the Lapidus procedure. You will be the ones paying back the money on audit, not the corporate entities or the so called thought leaders who are receiving hundreds of thousands of dollars (or more) to encourage you to utilize coding of questionable accuracy. As an example, I would refer PM News readers to the recently published Culper Research Report, November 15, 2022 regarding Treace Medical Concepts.


Allen Jacobs, DPM, St. Louis, MO



From: Bruce Smit, DPM


I too recognized the hazard of getting older as I aged. Many years ago as a young man and before my medical training, I played in a rock band in the Chicago area that played all the top 40 hits of the time. We were, thankfully, successful competing against a plethora of garage bands all who wished for "Rock and Roll success". We played record hops with the top DJs in Chicago's radio industry. We played with Herman's Hermit's and Wayne Fontana and the Mind Benders on stage at Chicago's Arie Crown Theatre in McCormick Place. We recorded a 45 rpm record at RCA Victor studios, and as it was time to release the single, The Beatles arrived! 


55 years later, I ran into the drummer by accident. He was still playing his guitar as a one-man band in the local lounges. We decided to "regroup" and with the help of two more formed a cover band. We have a regular gig at a local bar/grill and host about 75 guests at a time. What a blast we are having at age 76 years, grey hair (no pot bellies), and fortunately good health.


Bruce Smit, DPM, Frankfort, IL



From: Jeffrey Kass, DPM


I agree with Dr. Herbert’s opinion. If things aren’t changing, it would behoove someone to change strategy or legal representation. One would think that new legal counsel would be hungry to show their worth. Most other professions are advancing their legal scopes and our profession remains pretty stagnant in comparison. I notice most of the doctors in my state who increase their scope are the ones that leave the state. But, yet the state societies keep the same lobbyists and attorneys. Makes one wonder. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Jon Purdy, DPM, Howard Dananberg, DPM 


I see just as many neurologic conditions in my practice as the more common plantar fasciitis and ingrown nails. I send patients for lumbar x-ray/MRI far more often than foot MRI. Of the patients with complaints of back pain in association with neurogenic foot pain, I would estimate, ninety percent of those sent for lumbar studies have findings of significant pathology. They are then referred to neurosurgery.


Jon Purdy, DPM, New Iberia, LA 


I always insisted that patients had been evaluated by their physician PRIOR to being treated for any back pain issues. Two points: 100% of these patients who were in my study failed numerous treatments including surgery. Second, the treating back docs had NO IDEA how to resolve these complaints. It’s the vast majority of “mechanical” back pain complaints which resolve with proper orthotic management and this can be discerned from careful history-taking. 


Howard Dananberg, DPM, Stowe, VT



RE: Overcoming the Influence of the AMA

From: W. David Herbert, DPM, JD,


In 1967, the AMA declared that it was unethical for an MD to refer patients to chiropractors, but today chiropractors can obtain privileges on hospital staffs to perform spinal manipulation under anesthesia. A half dozen states allow psychologists to prescribe psychotropic drugs and at least one allows optometrists to perform lasix surgery. We know that a number of states allow nurse practitioners to practice independently.


Obviously, the influence of the AMA to block legislation by other professions trying to enlarge their area of practice is not what it used to be. Maybe podiatric leaders should hire some of the same lobbyists the chiropractors, optometrists, and the nurses use!


W. David Herbert, DPM, JD, Billings, MT



From: George Jacobson, DPM


When I first glanced at this post, my brain saw "Commercialization of Medicare." The television commercials for Medicare here in Florida are beyond commercialization; they are fee splitting. If a doctor offered to pay your Medicare premium for coming in, we'd be jailed. Some Medicare Advantage plans now also offer quarterly cash payments for out-of-pocket expenses. The TV commercials are frequently a bait and switch. You call the hotline for one thing and are switched to another. They have always had many additional benefits, but cash payments! If the health insurers get so much money per patient for these Advantage plans, how about reducing the Medicare premium for everyone and pay them less. 


We pay for some of this through our paychecks. Why should we have reductions in our reimbursements, when the payments are bloated to the insurers? Are commercialization and politicization of drugs and healthcare the same thing? My vote is yes. A good example of this is the current Covid vaccine commercials. They most certainly are commercialization, under the guise of being politically correct. 


George Jacobson, DPM, Hollywood, FL



From: Jeff Root


I agree that foot orthotics can be effective in the treatment of low back pain, be it an intentional or coincidental result. In addition, it is important to recognize that foot orthotics can also cause or aggravate foot, ankle, knee, hip, or back symptoms. That is why it is important to inform the patient that they should discontinue the use of their orthotics and contact your office immediately should their devices cause or aggravate such symptoms. This is a component of informed consent. I recommend that when prescribing and dispensing foot orthotics, the patient should be advised in writing as to the recommended break-in procedure and that the devices will cause changes in forces in the kinetic chain.


I also recommend informing the patient that while their orthoses may feel totally comfortable or may feel unusual at first, they should never hurt. If the devices hurt or are uncomfortable, it is an indication that they need to come back in for further evaluation. It is also important that the patient be advised to strictly follow the recommended break-in procedure even when their orthoses are totally comfortable, because they may develop symptoms such as knee, hip, or back pain as a result of ignoring the recommended break-in procedure.


Jeff Root, President, KevinRoot Medical



From: Morton I. Altman, DPM, Philip Radovic, DPM


As a retired podiatrist, residency director, and researcher, I am no longer surprised at what level pharmaceutical companies, medical supply manufacturers, and others will go to sell the public on their product. Sad what has happened.


Morton I. Altman, DPM, Gig Harbor, WA


I recently promoted one of these Lapidus systems and decided to stop as I share the same frustration as Dr. Oloff. Are aggressive marketing strategies and doing an end run directly to consumers improper? It’s what pharmaceutical companies began some 20 plus years ago when they successfully lobbied congress to allow advertising medications directly to consumers when it was considered taboo…much like advertising tobacco is not allowed today. Although some of these systems have inventive clamps and guides, their function is easily reproducible with conventional instrumentation. One can argue the benefit of informing the public in a general sense; however, the cost and complexity of these systems, in my opinion, are unnecessary.


Philip Radovic, DPM, San Clemente, CA



From: Pete Harvey, DPM, Paul Kesselman, DPM


When I dispense an orthotic, it is with the intention of helping the foot, heel, or ankle problem. If the patient returns in a few weeks or months and says their knee or back feels better, I say great. But, I claim no credit.


Pete Harvey, DPM, Wichita Falls, TX


Thank you to Dr. Jacobs for providing the most rational response to this issue. Over the last twenty years, I have performed hundreds, if not thousands, of peer review examinations and/or independent medical exams (IMEs) on no fault cases. In many of these cases, the patient was referred to a podiatrist only because the patient was in a car accident. There was no distal leg/ankle/foot pathology or trauma and these are clearly in No-Fault mills, and the patient is simply seen as a cash cow to run the revenue stream up.


The foot examination is typically a joke, with little references to any acceptable objective scopes of examination other than to justify an orthotic. There is a lack of follow-up documentation supporting any...


 Dr. Kesselman's extended-length letter can be read here.



RE: The Commercialization of Medicine

From: Lawrence Oloff, DPM


I would like to share my frustrations with the commercialization of medicine. I grew up in an era of medicine where surgical equipment companies would introduce doctors to their newest gizmo via reps and meetings. Some of these were true advancements, and other not. Doctors would attend labs, listen to experts, and would then incorporate new devices/implants into their practice that they felt had merit. We have now entered an era where companies target the consumer.


In essence, a backdoor approach to the doctor. Promises of better results and faster recoveries have flooded the marketplace via the Internet, and...


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



From: Jeff Pinsky, DPM


Like so much of the stuff we see and read on social media, only part of the story gets exposed. I know a few people within Anthem (now Elevance, though still operating under the Anthem brand in many areas) and regardless of pre-authorization, the billing (CPT, HCPCS, ICD, etc.) codes need to be correct and complete to get approved for payment. This didn’t happen in her case.


Also as the TikTok clip stated, we all know that the hospital and doctors did the billing, but the public has little to no insight into how medical billing works, and it’s always fun to blame the “big evil insurers”. Patients shouldn’t have to resort to exposing their medical history on social media to get claims properly...


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



From: Howard Dananberg, DPM


In 1999, I published an outcome assessment study in JAPMA on 32 patients considered at or near medical endpoint with chronic lower back pain (CLBP).  All were treated with custom foot orthotics designed to specifically mobilize the 1st MTP joint. These patients were followed for an average of 13.9 months. 84% reported substantial recovery as measured using the Quebec Back Pain Disability Scale.   


In a separate study delivered at the 3rd World Congress on Lower Back Pain, I described the effects of the same type of orthotics on hip extension through the end of single support phase.  There was an almost 50% improvement in range at follow-up (from 7 to 13 degrees).


It is the improvement in hip extension which is the most important factor in the podiatric management of CLBP. This improves pre-swing mechanics which ultimately relieves iliopsoas origin stress in the lumbar spine, disks, and intervertebral septa. Since this pathological motion is repeated thousands of cycles daily, resolving it produces outcomes which tend to be excellent. It represents a non-specific repetitive stress to the lower back region which cannot be relieved by other methods. Podiatrists should be at the core of every lower back treatment clinic worldwide.   


Howard Dananberg, DPM (retired), Stowe, VT



From: Allen Jacobs, DPM


While there would seem to be certain circumstances in which foot pathology (e.g., excessive pronation, rigid supinated foot) may be a contributing or even causative factor of mechanical back pain, I would urge caution to the readers. Asking a patient if they suffer from back pain, and then suggesting that orthotics might be helpful, opens a potential quagmire. I recently acted as an expert witness in a malpractice case against a podiatrist who successfully treated a patient for a Morton’s neuroma. The patient mentioned unilateral paresthesia in one leg. In hindsight, the patient was eventually diagnosed with a rare spinal-dural AV malformation. 


Unfortunately, this resulted in a permanent neurologic deficit. The podiatrist was alleged to have failed to recognize the serious nature of the back pathology, leading to a delay in diagnosis and resultant irreversible progression of the neurologic deficit. Back pain may be mechanical in nature, but may be associated with spinal stenosis, infection, tumor, spinal nerve compression. In the case I referred to, the patient was under concurrent management of a primary care physician (also named as a litigant) for back pain. 


Unless you are prepared to complete a detailed clinical and necessary radiographic or electrodiagnostic studies for the evaluation of acute or chronic back pain, should you undertake the responsibility of treating back pain with orthotics (and some have actually suggested sinus tarsi “stents”), make sure that a capable physician has taken the responsibility of diagnosing the etiology of that back pain.


Allen Jacobs, DPM, St. Louis, MO



From: Greg Caringi, DPM


As I have gotten older, I put together a rock-and-roll cover band with some of the other docs in my community as a reaction to many of my high school friends joining ukulele groups and playing pickleball. I hope that future generations do not ignore the wisdom and work of those who went before them. Our parents' generation is all but gone. I still have many questions that I wish I could ask them.


Greg Caringi, DPM, Lansdale, PA



RE: Qutenza (Ronald Carlson, DPM)

From: R. Alex Dellinger, DPM


I believe one must be very careful when billing for this product. Their own billing guide online states: "No existing CPT code is specific to the QUTENZA application." However, their website lists some of the following CPT codes:


64620 Destruction by neurolytic agent, intercostal nerve 

64632 Destruction by neurolytic agent, plantar common digital nerve 

64999 Unlisted procedure, nervous system 

64640 Destruction by neurolytic agent procedures on the somatic nerve


I don't believe billing for one of the above CPT codes after performing a topical application of Capsaicin would be appropriate (except possibly 64999). And to do this three times? So, the first two times weren't "destructive"? I found a billing and coding article from CGS Region J15 Part B regarding Qutenza: My advice is "provider beware".  


R. Alex Dellinger, DPM, Little Rock, AR



RE: The Power of Your Patients and the Media

From: Paul Kesselman, DPM


The power of the media and your patients working together can reverse payment denials. A suburban Chicago area resident recently went on TikTok in order to obtain a reversal of a $40K payment denial for kidney tumor surgery. This, even though the hospital and physician had obtained pre-authorization from Anthem. This recent story shows the power that you and your patients along with the media can leverage over these giant monopolies.


One cannot expect to generate much empathy over small denials typically seen in many physicians’ offices. However, lumped together, a union or group of patients filing a similar action against an insurance giant may be able to leverage equivalent results. 


Paul Kesselman, DPM, Oceanside, NY



From:  Ivar E. Roth DPM, MPH


With all my patients I always include a question if they have any back problems. For those patients, I almost always recommend orthotics. Most all who get them are very satisfied and I would say 25% of the patients coming in with back pain order the orthotics. I think all podiatrists should do this. You would be surprised how many patients you can help.


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



From: Jengyu Lai, DPM


The company said patients may not experience the benefits until the third application. I have done the third application to my first patient and will follow him next week. He did say it helped after the second application. I also had a first application on the second patient who said he had the worst pain immediately after the application. But he is looking forward to the second application.


The company provides billing information and does the benefit verification prior to each application. They also advertise the clinics where Qutenza is available. I have received two patients from its website in the past three weeks.


Jengyu Lai, DPM, Rochester, MN 

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