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From: Janet McCormick


Though I am not a podiatrist, I fully agree with Dr. Lauren Perico's description of necessary foot care and that it is important to prevent foot problems from getting serious. However, many persons cannot perform some of these self-care tasks for various reasons, such as poor eyesight, arthritis, and other deficiencies, even cognitive ones. These persons have two options: having a caregiver perform the care or going to their podiatrist for monthly care.


Two problems are obvious with these options. First, podiatrists would be (and many are already) totally overwhelmed with RFC in their practices; and second, these visits would be self-pay/not be covered by Medicare or insurance. An additional problem would be that the podiatrist could not take more treatment-oriented care.


A resolution of these problems was found many years ago by physicians through the hiring of licensed extended care professionals. For example, many derms and plastics hire estheticians to perform the routine care that is important for their patients and to perform non-medical care. These services are also not covered by Medicare or insurance. 


Many podiatrists are reducing their overload of RFC by hiring trained nail techs to perform this care. These technicians are state licensed in performing the skills within RFC and have completed a medical nail tech program of 20 modules online, followed by an internship to prepare them to work appropriately in a podiatry office. 


Janet McCormick, Frostproof, FL

Other messages in this thread:



From: John M. Giurini, DPM


I would like to join my classmates and send along my deepest sympathies and prayers to the family of Dr. Tom Shock. Words are not enough to express how stunned I was to receive news of not only Tom's passing but the circumstances of his death. Tom was a classmate and a friend. The CCPM Class of '83 had bonded after their 1st-year and had become a very close and cohesive class. Tom was an important part of the "Motley Crew", with his good-natured personality and smile. He will be deeply missed by his classmates, patients, friends, and most importantly his family.


John M. Giurini, DPM, Boston, MA




I too am stunned by the news of the fatal shooting of our classmate, Tom Shock. CCPM Class of 1983, and our profession, have lost a kind-hearted and generous soul. Our deepest sympathies and prayers go out to Tom’s family.


Ross E. Taubman, DPM, Franklin, TN



From: Tim Shea, DPM


As expressed by Dr. Kevin Kirby, I am stunned by the manner and death of Tom Shock, DPM. As one of his instructors at CCPM, I always found Tom to be immensely professional and personable to all around him. He always had a smile for everyone. His attitude was extremely positive and inquisitive. Over the years, whenever we would meet, his demeanor was always the same. My thoughts and prayers go out to his family and friends.


Tim Shea, DPM, Concord, CA



RE: CA Podiatrist Fatally Shot

From: Kevin A. Kirby, DPM


One of my classmates from the CCPM Class of 1983, Dr. Tom Shock, was shot in front of his home in Lodi on Wednesday night by an unknown assailant. I knew Tom well and his sudden, unexpected death has hurt me terribly because Tom was just one of the nicest, friendliest guys you could ever know. He never said a negative word about anyone and always had a smile on his face. Tom was one of those guys who everyone liked since he had such a positive, uplifting attitude about everything.


Dr. Shock started his practice in Lodi in 1984, and served the community of Lodi with excellent podiatric medical care during that time. Tom had just retired two months ago, took a short vacation to Europe with his wife, and was ready to start enjoying his hard-earned retirement after...


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



From: Steven Kravitz, DPM


Marc Benard, DPM has been the most dedicated leader of the ABPM. He has been its heart, soul, and inspiration taking it from a fledgling organization, facing difficult times, to a thriving and respected certifying board that has helped shape and mold our profession to its current status today. We wish Marc the best in moving on to his next phase of future accomplishments and whether that be professional, family, social and/or, I suspect, his interests and wonderful talent in music and the arts.


That said, there is no individual better suited to take the reins and assume the leadership and guidance as the executive director of ABPM than James Stavosky, DPM. He is a respected podiatric physician and surgeon, educator, speaker, and author in addition to assisting other organizations in leadership roles. Congratulations, Dr. Stavosky and to ABPM for making a superb selection. 


Steven Kravitz, DPM, Winston-Salem, NC



RE: Botox Has Practical Uses in Treating Foot Conditions: PA Podiatrist

From: Bret Ribotsky, DPM


I applaud Dr. D’Angelantonio for getting positive press, and I hope the writer missed something when the article was written. We all know that Botox is NOT a filler/implant; it is a neurotoxin that interrupts nerve conduction. I have found great success using Botox for hyperhydrosis and for children who are toe walkers who can stand with the heel on the ground. I have always postulated for Botox’s possible use in Jones fractures to take the pull off of the peroneal longus muscle, but have never used it. 


When it comes to “orthopedic pad” (as its called in the article) we all know you need an implant, not a neurotoxin. Use PSTTA (pedal soft tissue temporary augmentation) as I reported in 2013.


Bret Ribotsky, DPM, Boca Raton, FL



From: Elliot Udell, DPM


When I was in podiatry school in the late '70s, Dr. Seymour Frank, who chaired the department of surgery, taught us that equinus deformities account for far more pedal pathology than most podiatrists realize. He taught us how to test for equinus deformities, but unfortunately there were no really good non-surgical treatments available at that time.  


Dr. DeHeer's brace is an answer to this problem and, outside of the operating room, is probably the only solution. In our practice, we have been using his equinus brace for over a year and we have been very impressed with the results. Not only does it address obvious cases of equinus, but we are seeing it address other problems secondary to equinus such as plantar fasciitis, which can be exacerbated by limitations in ankle dorsiflexion. My patients are very grateful to Dr. DeHeer for doing the research and developing a product that is giving them a great deal of relief. 


Elliot Udell, DPM, Hicksville, NY



From: Donald Blum, DPM, JD


It seems to me that CMS should create a category for ALL specialists. Why is a podiatry E/M different than that of a hand specialist, dermatologist, or even a foot and ankle orthopedist? We are expected to go through the medications, flu shot, eye doctor visit (diabetics), A1C, evaluate for falls, etc. What is the difference of going to the hand doctor with a broken finger or wrist as the chief complaint versus a patient going to the MD/DO foot and ankle specialist with a chief complaint of an ingrown nail or bunion deformity, or going to the DPM?


I believe the CMS change should affect the E/M for ALL specialists.


Donald Blum, DPM, JD, Dallas, TX



From: Edward Orman, DPM


Dr. Jacobs mentioned about having patients return at another date for an E/M service to work-up a new complaint during a "diabetic foot care" visit. We are not the only specialty concerned about adding modifiers to E/M services or other "surgical" services. I recently had a full body scan by my dermatologist. She noted a suspicious lesion on my hand that she wanted to biopsy. But she was fearful of an "audit" due to too many biopsies and modifiers during E/M services. She gave me a topical steroid and told me to return the following week if still present. The lesion didn't resolve, so I returned for the biopsy. 


By the way, it was a squamous cell carcinoma in-situ. Suppose this was a more serious lesion where delayed treatment could be life- or limb-threatening. CMS makes us ALL fearful to do the right thing for fear of audits by contractors who are paid a percentage of what they recoup. 


Edward Orman, DPM, Perry Hall, MD



From: Allen Jacobs, DPM


Several recent and related discussions in PM News deserve serious attention by all practitioners. The letters noted the considerations by CMS that a separate classification of E/M coding by podiatric physicians has been discussed. There is no reason that this regulation should be restricted to the podiatric physician. Does anyone really believe that an orthopedic surgeon conducts a full or even partial history and physical examination? Of course they don’t. They conduct a history and physical relative to the complaints or concerns for which the patient has presented. The same is true for a podiatric physician. Furthermore, such a consideration devalues the examination by the podiatric physician. If a patient presents with paresthesia or dysesthesia of the foot or leg, why would a complete lower extremity or lower extremity focused neurologic examination be of less value? 


I have had many patients tell me that I am the first doctor in their entire lives that is ever...


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



From: Patrick (Pat) Caputo, DPM, Don Peacock, DPM


This is a terrible idea. TERRIBLE! We need less codes, not more. This has $40 written all over it. Can you run your office on $40 visits? 


Patrick (Pat) Caputo, DPM, Holmdel, NJ


I could not agree more with Dr. Musella. Providing foot care to our patients is a vital part of our healthcare system. The limb salvaging and therefore life saving roles foot care plays cannot be overstated. The coding should be made easier to implement in our offices. The rules for foot care need simplification, and the importance of routine foot care needs to placed at top level priority in our treatment of patients. 


Don Peacock, DPM, Whiteville, NC



From: Al Musella, DPM


This might be the opportunity to get rid of the crazy rules for foot care. Perhaps we should work with CMS to create a podiatry specific G code which includes a subsequent visit, treatment of nails, corns and calluses as well as prescriptions for creams or shoes and is paid at the level of the "subsequent visit" code for MDs. Remove all of the nonsense about class findings, non-covered services, 60-day global period, and the need for us to send patients to their MD every 6 months.  


We might get paid a little less per patient, but it would remove so many headaches, it would be worth it. It would also greatly reduce fraud and abuse and unfair competition. Many of my patients tell me they have always been covered under Medicare when I tell them they are not covered.


Al Musella, DPM, Hewlett, NY 



From: Keith L. Gurnick, DPM


"Shockingly, CMS wants to create podiatry-specific G codes for E/M."


This is probably so that CMS and any other insurance company computers will be programmed to immediately distinguish a "Podiatry" E/M "G" level service from that billed by any other provider billing for the same level E/M service. Podiatry will be contracted at a lower rate. To me, this seems like a bad idea and is discriminatory. The same level E/M code should be paid based on payment allowance for that specific level of coding, not based on the medical specialty. Now, on the other hand, if they are going to pay podiatry more for the same level "G" E/M code, I am just fine with that.


I ask PM News readers, what are the chances of that happening? Will "G" codes only be for Medicare? Will we be allowed to append a G code with a -25 modifier like we can do with an E/M code, when applicable? It looks like we got more trouble right here in River City.


Keith L. Gurnick, DPM, Los Angeles, CA



Kent Biehler, DPM, Middleburg FL


From an evidence point of view, I agree with Simon Bartold's statement... it's a myth that running shoes reduce injury. It goes along with the similar mythology regarding subtalar joint neutral orthotics that claim to control motion by reducing pronation and putting feet in a “perfectly healthy position”.


Ten years ago, I started working with Dr. Dennis Shavelson's functional foot typing. It is a well thought out innovative paradigm for diagnosing foot pathology. It produces a vaulted, centered custom foot orthotic that, in my ten year experience, replaces subtalar joint neutral orthotics. His protocols are less myth and more time tested reality. It brings control and certainty back when practicing individual biomechanics. The major draw back is they can't be mass produced with one size fits all.


Kent Biehler, DPM, Middleburg, FL



From: Steven Kravitz, DPM


I’d like to thank Dr. Sutera for discussing and bringing to attention that DVT associated with long-term air travel and resultant pulmonary embolism is all too often not well recognized. There are a few well done scientific articles on the topic because it is very difficult to follow up the fact that the DVT and especially PE is often not noticed until several days following the air travel. This presents in many variables that can make the causality scientifically difficult to make. 


A very good paper terms the phrase “Economy Class Syndrome” identifying the differentiation between a business class seating long-term travel and sitting in a tight seat in the rear of the plane with knees, hips, and ankles all flexed at 90°. While traveling from ther West to East coast U.S. is a concern, much more concern is transcontinental travel to the Mideast or Asia. These flights can incur more than...


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



From: Steven J Berlin, DPM


I want to congratulate Dr. Robert "Bob" Hilkemann on his dramatic rise from retired podiatrist to the highest office in the State of Nebraska (even if it was just for two days). Bob and I served many years together on The Fund For Podiatric Medical Education (now the APMA Educational Foundation). I just knew he had more successful days ahead. My sincerest congratulations to you on your service to the citizens of Nebraska and to your profession.  


Steven J Berlin, DPM, Baltimore, MD



From: Brian Lee, DPM


I loved the story about the three generations of DPMs in the Caneva family. Reno was one of my residency directors back in “the day”, which was 1985! Great guy. I’m glad to see him still having an impact on the podiatric community. 


Brian Lee, DPM, Mt. Vernon, IL



From: Allen Jacobs, DPM


Mark Twain is credited as saying, "There are 3 types of lies; lies, damn lies, and statistics." 


Dr. Paul Dayton has devoted considerable time and effort to examining the current state of bunion deformity and correction. His work is worthy of consideration. It appears to me that those positing opinions in PM News on this subject may not be particularly familiar with his work regarding the need for stability and triplane 1st ray correction. 


One question which needs to be addressed is whether or not...


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



From: Dieter J Fellner, DPM,


Dr. Borreggine succinctly provides an excellent rebuttal to the overtly enthusiastic (premature) endorsement of Lapiplasty.  Meanwhile, citing the research evidence, Dr. McAleer, perhaps unwittingly, provides further ammunition to a counterpoint of view: the Lapiplasty has yet to be put to the test, for long-term outcome success. Conspicuously absent also from the literature review is the long-term outcome for Lapidus.


On the issue of frontal plane rotation: I agree that this should be evaluated pre-operatively and addressed surgically, when present. This can be easily accomplished with a regular Lapidus (and fixation of a surgeon’s preference). This problem does not specifically require the ‘Lapiplasty’ with its complex cutting rigs, an over-engineered bone clamp, two plates and a bag of screws.


While obvious to the foot surgeon, this information is lost to the Lapiplasty marketing hype. I will go one step further: frontal plane rotation can be addressed differently, much more easily and without expensive fixation. I have addressed this issue in a lecture presentation prepared for the AAFAS, New Orleans meeting June 2018. I have posted the lecture on YouTube for open access and will provide narration in the next week or so.


Dieter J Fellner, DPM, NY, NY 



From: Ralph Graham, Larry Aronberg, DPM


In regard to the discussion about Lapiplasty, I agree with others that this is just a method for performing a fusion at the metatarsal cuneiform joint. In addition to other comments which I endorse, why on earth is it named “plasty”. The last thing it produces is mobility so it is not a sensible title.


Ralph Graham, Witham, Essex, UK


I'm concerned about the biomechanical effect of fusing the 1st ray. I have a friend in his late 50s who hikes, plays golf, and tennis. He's considering getting bilateral procedures (I would send him to another DPM since that's beyond my training). Lapiplasty may be too new for long-term results to be apparent, but Lapidus itself is not. Any comments? I can't even envision an orthotic that could compensate for a fused 1st.


Larry Aronberg, DPM, Lake Worth, FL



From: JP McAleer, DPM


Colleagues, I invite you to read the requested sources found below. I agree it is a disquieting thought when we realize that there may be a better way to approach our surgical specialty. I have found that the Lapiplasty 3D Bunion Correction Procedure has been a ‘game changer’ for my patients, and I am proud to offer it to them. I respectfully invite you, the podiatric and foot/ankle ortho community, to read Dr. Paul Dayton’s book -Evidence-based Bunion Surgery as well as the current journal literature touting the benefits of triplane correction.


30% radiographic recurrence after Scarf at 10 years (Bock, et al., JBJS 2015)

65% radiographic recurrence after proximal open wedge at 2.4 years (Iyer, S et al., FAI 2015)

73% radiographic recurrence after distal chevron at 8 years (Pentikainen, et al., FAI 2014)

73% & 78% radiographic recurrence after Scarf and chevron respectively at 14 years (Jeuken, et al., FAI 2016)

Incomplete reduction of the sesamoids - 10x recurrence risk (Okuda, et al., JBJS 2009)

Incomplete reduction of metatarsal rotation - 12x recurrence risk (Okuda et al., JBJS 2007)


Also - please note that I was misquoted. I stated “Traditional bunion surgery has up to a 70% rate of recurrence based upon the literature.” I am working on having the printed article corrected. 


JP McAleer, DPM, Jefferson City, MO



From: Joseph Borreggine, DPM


The “new” bunion procedure that is called the lapiplasty which was brought to fruition by Dr. Paul Dayton, et al. and his team certainly has “changed” the way we look at the biomechanics  of a bunion deformity, let alone, how to correct it. But, the question I pose to the PM News readers and to my podiatric colleagues: is this bunion procedure the pinnacle of podiatric surgical success because of its continual outcome of “reproducible” results along with reduction in bunion deformity re-occurrence? 


Or is this procedure driven like most of our profession’s innovations by the vendor dollars created by performing said procedure? Or is this procedure’s ability to stay in the limelight of surgical success fueled by the...


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



From: Patrick J. Nunan, DPM, Richard A. Simmons, DPM


While I commend the new innovation of bunion surgery, I would like to know the source of the comment that traditional bunion surgery fails 70%!  Having been in practice for 33 years, I have yet to see that many bunion procedures fail at that rate. If bunion surgery had that high of a failure rate, very few, if any, would be performed. Malpractice would be outrageous and hospitals, insurance plans, etc. would not allow the procedure to be performed.  


Patrick J. Nunan, DPM, Savannah, GA


I hope this article about this one-year-old, “game-changing” lapiplastly, 100% bunion correction procedure was more “tongue-in-cheek” rather than something that is supposed to be factual and peer reviewed.


Richard A. Simmons, DPM,  Rockledge, FL



From: Stephen Kominsky, DPM


I read and have been reading PM News since its inception. Many times over the years, I have disagreed with comments and assertions made by our colleagues either through an interview for a media outlet, or straight up for this platform. I generally hold my tongue and don’t comment, but this time I have to.


In the piece regarding the lapiplasty procedure, Dr. McAleer asserts that “traditional bunion surgery has a 70% recurrence rate.” I find that comment to be a lot of things including egregious, damaging, and laughable, but mostly, just wrong. Yes, of course there is an inherent recurrence rate with bunion surgery, but with today’s level of training and education, and the skill of the today’s podiatrist, the rate is more like 10%. 


The lapiplasty is a good tool (that IS what it is, an expensive piece of equipment used to accomplish the Lapidus procedure), but it is NOT responsible for the reduction of recurrence; make no mistake about that. A Lapidus procedure would accomplish the same thing. But that is not the point. To simply disseminate a false piece of information is misleading and smacks of trying to increase sales of the equipment for the company that manufactures it.  


Stephen Kominsky, DPM, Washington, DC



From: Brian W. Fullem, DPM


In reading Dr. Zuckerman's comment on Shockwave Therapy, I disagree with his statement: "Comparing high-energy FDA-approved ESWT with the EPAT is false and misleading. They are entirely different modalities with different uses and outcomes." 


EPAT produces a sound wave; it is commonly known as Radial Extracorporeal Shockwave Therapy. The old terminology would be low energy, whereas the machine is similar to the Dornier EPOS. The new terminology is Radial ESWT and Focused ESWT. They both produce sound waves. There is also no difference in the literature as to which technology works best, both produce similar results which are in general better than any other technology for soft tissue injuries. 


I highly recommend that people read this medical article. The article is a... 


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

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