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RE: Z-Coil Shoes (Michael Lawrence, DPM)
From: Kevin A. Kirby, DPM

I have had some clinical experience with Z-coil shoes that I thought might be of help for my colleagues who have not yet suggested these unique shoes for their patients. Z-coil shoes have a rather large spring which connects to the heel portion of the sole of the shoe which provides unusually good shock attenuation characteristics to the shoe.

The shoe may be modified with springs that have different stiffnesses which may be used to adjust to the patient's body weight, to increase or decrease the height of the heel of the shoe and/or to increase or decrease the frontal plane rearfoot stability of the shoe. Z-coil also sells a cover that effectively hides the rearfoot spring so that the shoe appears to more traditional in construction. The shoes come both in a slip-on and lace-up styles. I have not had any patients that have had instability problems, trips or falls that can be attributed to the shoes.

I have found some success with Z-coil shoes in my patients with plantar heel pain (i.e., plantar fasciitis). However, the best indication for Z-coil shoes, in my experience, are for those patients that suffer from chronic retrocalcaneal bursitis and/or retrocalcaneal spurs. In these patients, I recommend the slip-on Z-coil design without a posterior heel counter to avoid chronic compression and/or shearing forces from the posterior heel counter on the posterior calcaneus. In addition, the higher heel-height differential of the Z-coil shoe, along with the shock attenuation characteristics of the rearfoot spring likely also decrease the tensile force from the Achilles tendon on the posterior calcaneus.

The Z-coil shoe, in combination with a well-designed foot orthosis, often renders even the most recalcitrant cases of chronic retrocalcaneal bursitis asymptomatic. I find them to be a very useful tool in the treatment of these patients. I do not have any financial interest in Z-coil shoes.

Kevin A. Kirby, DPM, Sacramento, CA,

Other messages in this thread:



RE: Heel Pad Stabilization (Calvin Britton, DPM)

From: Tip Sullivan, DPM

If your conservative efforts fail, I would certainly try the thick GraftJacket and pull it across the entire heel so that it can incorporate around the edges and stay there. Also, I might see if she was willing to use a posterior rocker bottom @20 degrees. If she has the other things that you say — pronated calcaneal position -- I would inform her of potential structural changes that may likely occur in the future, and offer her some options of treatment--- i.e.,-see if she wants to treat the problem at hand or the whole ball of wax.


Tip Sullivan, DPM, Jackson, MS,



RE: Medicare Umbrella Organizations and Chart Review (Dan Klein, DPM)

From: Michael M. Rosenblatt, DPM

Dr. Dan Klein reported that Medicare and Medicaid have outsourced auditing functions to commercial companies to verify chart information and coding. You have both a right and obligation to be sure that the companies so designated are actually authorized by the Government agency they say they are representing before you send them chart data. One way you can do this is to demand proof of their authorization in the form of some kind of signed contract from the Governmental agency.

You can also contact your local Medicare Intermediary to check with them. Document your vetting in written form after you are finished, and date it. HIPAA regulations are very demanding. Some outside auditors may include this documented permission along with their request. Others may not.

After you are audited, there is a possibility that they may demand you return money, and/or even penalties, based upon your charts. It has been my experience that these audits are rife with errors of all kinds, including ordinary arithmetic mis-computations. These audits must be thoroughly contested and fought. I have been a part of such audit defenses where penalties have been whittled to less than 1/3rd of their original amount, or even abandoned entirely! Just because they demand money from you does not mean that you should accept their judgment.There are some new audit defense techniques and systems that are very powerful. It would be a shame not to take full advantage of them.

Michael M. Rosenblatt, DPM, San Jose, CA,



RE: AFO Brace/Shoe for CMT (David B. Arkin, DPM)

From: David J. Levine, DPM, C. Ped

There are a variety of ways to provide the bracing this patient needs, but since the deformity is rigid, the bracing will not offer him as much help as modification of his shoes will. Accommodating the deformity and providing him with a wide base of support is the most important issue to address in this situation. Shoe modifications are an extremely under-rated and under-utilized way to help patients from a mechanical perspective.

Shoe Modification for CMT (Courtesy Dr. David Levine)

Above is an example of a shoe modification that would help this individual. My only conflict of interest is that I have a shoe lab in my office with a technician who does nothing but shoe modifications. They work!

David J. Levine, DPM, C. Ped , Frederick, MD,



RE: Short-Term Coverage For Practice (Name Withheld)

From: Mark E Weaver, DPM, Jeffrey Kass, DPM

It has been my policy (and several of the other podiatrists here in Fort Myers, FL) to cover for our colleagues in distress for a limited period of time free of charge. We try not to 'steal' a single patient, and would feel bad if we were forced to. Over a long period of time, we would try to cover our net expenses. I would say 30-40% depending on the patient mix and local expenses. Remember most of our expenses are fixed. I'm sure this could be found universally. Just ask.

Mark E Weaver, DPM, Fort Myers, FL,

I think Name Withheld’s suggestion is a good one. I have covered many of my colleagues practices, whether they were away on vacation, tending to an ill relative, etc. I think the more you are away and don't have coverage for your practice, the more trouble you will have (i.e., losing patients). I wish you a speedy recovery, and if by chance, you are in my vicinity please do not hesitate to call.

Jeffrey Kass, DPM, Forest Hills, NY,



RE : Benfotiamine Shown to be Efficacious in Treating Diabetic Peripheral Neuropathy (Michael Turlik, DPM)

From: Multiple Respondents

I have been using Neuremedy (benfotiamine) for the past 2 years with 30-40% success rate in the treatment of peripheral neuropathy. I have seen no side-effects with this product, which is well-tolerated.

Paul A. Sommer, DPM, Valpariso, IN,

In the study, Benfotiamine in Diabetic Polyneuropathy (BENDIP): Results of a Randomised, Double Blind, Placebo-controlled Clinical Study, the primary endpoint was defined as an improvement in subjective symptomatology, i.e., did patients with neuropathy feel better after receiving benfotiamine? The study showed to a statistically significant level of confidence, p=0.033, that these patients had improvement in their symptoms after a six-week course of benfotiamine.

Of great interest is another study, Benfotiamine in the Treatment of Diabetic Polyneuropathy- a Three Week Randomized, Controlled Pilot Study (BEDIP Study). In this study, a statistically significant ( p=0.0287) improvement in the neuropathy score was observed in a group of diabetic patients with peripheral neuropathy after being given benfotiamine when compared to placebo-treated controls.

In the landmark study, high prevalence of low plasma thiamine concentration in diabetes linked to a marker of vascular disease, it was shown to a high level of statistical confidence, p<0.001, that diabetics have 75% less circulating plasma thiamine when compared to non-diabetics. Thiamine deficiency is a well-known cause of peripheral neuropathy. It should, therefore, not be surprising that benfotiamine, a lipid-soluble derivative of thiamine with high bioavailability, has been shown to reduce the symptoms of diabetic peripheral neuropathy.

In light of these findings, practitioners may want to measure plasma thiamine levels, when possible, prior to initiating benfotiamine supplementation. Readers are welcome to review these and other abstracts at

Richard Mann, DPM, President, Realm Labs,

It's great to see that PM News has incited so much debate and controversy regarding performing double-blind randomized studies to show the efficacy of medications or treatments we perform daily in our offices.

In the past, I've referred many patients complaining of pain in their feet or legs to neurologists with the recommendation to evaluate the patient for Neurontin, Cymbalta or Lyrica. Several weeks later, the patient returns stating that the discomfort has subsided or hasn't changed, but they hate the feeling of being sleepy or drugged from the medication.

I've been using benfotiamine in my office for the last 2-3 years. The patients either love it or at worst see very minimal changes, but, no untoward side-effects. So, in the past, I've been a hero to many patients because I've given them relief.

Many of the earlier treatments in podiatry were based on anecdotal information. So, continue with the double-blind randomized studies, but, please don't forget the suffering patients.

Edward Fryman, DPM, Seaford, NY,



RE: Cuboid/Peroneal Pain (Mark Aldrich, DPM)

From: Howard Dananberg, DPM, Lloyd S. Smith, DPM

I see this type of problem quite often. The most common complaint involves pain in and around the cuboid, but can also present as vague dorso-lateral foot pain. The best approach is manipulation of the cuboid. Click here for a downloadable article (with photographs) on this topic. Orthotic management is fine once the cuboid has been mobilized. Like all of our podiatric skills, manipulation takes time to master...but once this is learned, positive outcomes become very common place.

Howard Dananberg, DPM, Bedford, NH,

Many of these cases are longitudinal splits in the peroneal (longus and/or brevis) tendons starting at the malleolus and sometimes extending to the base of the 5th. If conservative treatment fails ( I use the full gamut of options in most cases including 4 to 6 weeks in a CAM-walker if surgery is rejected), an MRI should be obtained. Although MRIs often fail to show these splits, discussion with the radiologist can be helpful. Certainly, if any indication of tendonopathy exists, a longitudinal tear is likely. Repairs are simple and involve retubularizing the involved tendon - both the longus and brevis need to be examined from the ankle to the base of the 5th metatarsal.

Lloyd S. Smith, DPM, Newton, MA,



RE: Cuboid/Peroneal Pain (Mark Aldrich, DPM)

From: Ira Meyers, DPM, Jeffrey Trantalis, DPM

I see this a lot in runners. It usually occurs after a hard workout or race or after changing from old to new shoes. High dye strap with Elastoplast and Theraband exercises usually work within 1-2 weeks. If easily accessible, I'll add modality PT-elec stim, ultrasound. Massage and gentle manipulation help as well. For a first time occurrence, I only recommend orthotics if the biomechanical exam warrants it. This is strictly a history and exam diagnosis. I have had many patients (including myself on my first bout) think it was a stress fracture. However, there is usually minimal edema and only occasional pinpoint pain. But, ambulation is quite painful. X-rays are normal, and since pain usually resolves in 1-2 weeks, I rarely need to order other diagnostic studies.

Ira Meyers, DPM, Philadelphia, PA,

I do not want to get involved with the didactic biomechanical dissertation presented by the previous doctors. One should consider the possibility of a hypermobile cuboid or subluxed cuboid. The pain across the arch with migrating symptoms are consistent with the diagnosis. There are occasions when plantar fasciitis diagnosis is made when it is the peroneal tendon involved The peroneal tendon is not tracking correctly in the peroneal groove. No orthotic or shoe will help if the cuboid is out of alignment. A very simple test is to have the patient make a circle with her foot both clockwise and counter-clockwise. If there is a limitation in motion, you have made your diagnosis. This is 100% for the diagnosis when presented.

Jeffrey Trantalis, DPM, Deerfield Beach, FL,



RE: Benfotiamine Shown to be Efficacious in Treating Diabetic Peripheral Neuropathy (Michael Turlik, DPM)

From: Multiple Respondents

With all due respect to Dr. Turlik’s analysis, I believe what matters is real life. I see results equal or better to prescription drugs for neuropathy using benfotiamine. I believe there is a place for both types of treatments. Really, there are few studies available for most treatments performed in our offices each day. However, we successfully treat patients and the studies have minimal relevance. As a matter of fact, I could take most studies and distribute them to 10 researchers and there would be multiple problems found.

We should base out treatment on our expertise as physicians and what is best for patients. We can use studies for what they are worth, a guide. Just because insurance companies care about studies, this should not change our treatment plan.

Marc Katz, DPM, Tampa, FL,

I acknowledge Dr. Turlik for his critical evaluation of the paper on benfotiamine’s efficacy. He shows how we can be misled by poorly-written papers that have entered the literature. Without his critical analysis, many of us could be hoodwinked by sales reps and corporate-sponsored speakers who might try to convince us that evidence-based medicine supports the use of this dietary supplement in all cases of diabetic neuropathy.

I have another question about the use of benfotiamine, which is a lipid-soluble form of thiamine or Vitamin B1. Why not take a simple blood test and see if the patient has a thiamine deficiency before giving the patient a thiamine supplement? Thiamine deficiencies definitely can cause peripheral neuropathy, but If there is no evidence that the patient has such a deficiency, putting the patient on benfotiamine is really practicing hocus pocus rather than evidence-based medicine.

Elliot Udell, DPM,
Hicksville, NY,

I think this represents an over-simplification of the condition. Neuropathy is a complex, multi-factorial syndrome. It is more than the absence of a B vitamin derivative. I believe the best we can say is that benfotiamine may be one part of a complex protocol that shows efficacy in the treatment of neuropathy. It is important to identify and address all mechanisms whenever treating any pathology. For this reason, relying on one nutrient as "the treatment" for any condition is foolhardy. Likewise, evaluating one nutrient as a protocol and dismissing it as non-efficacious is short-sighted and unfair to the big picture.

Bob Kornfeld, DPM, Lake Success, NY,



RE: Latest Research on Subtalar Joint Axis Location (Kevin A. Kirby, DPM)

From: Simon Young, DPM, Dennis Shavelson, DPM

Bravo. It is great seeing new research which can help us utilize biomechanical principles in our daily lives. This will help us understand pedal pathology better and help in guiding us to fabricate a more appropriate orthotic devices which will result in better patient outcomes.

JAPMA published an article, although supported by a lab, which showed that custom-molded orthotics reduced our energy consumption during gait.

Simon Young DPM, NY, NY,

I read with great anticipation Dr. Kirby's posting announcing “some recent research that may greatly change the way we view the forces and moments that affect foot and lower extremity function” until I realized that it was authored by HIM! For years, I have had difficulty understanding what Kevin is saying. I have debated his STJ Sagittal Axis Theory vs. my Neoteric Biomechanics Theory, stating that his theory required engineering and research skills that mainstream podiatry doesn’t possess.

Of my theory, he wrote that “your approach of foot biomechanics may suit many podiatrists very well and may allow them to progress to a better understanding of foot and foot orthosis function that they may not have been able to achieve otherwise” and then added, “You may use that quote as long as you use it along with my other quote, "Unfortunately, I see your model as a throwback to the Root model that I have worked so hard to get the profession to move away from for the past quarter century. Therefore, I simply don't see much benefit taking podiatrists back a step or two in sophistication, when they should rather be keeping more in step with the mainstream international biomechanics community and their prolific research on foot and lower extremity function."

I read Dr. Kirby's article and for a moment, considered applying to a fellowship at The Penn State Biomechanics Lab but I had charts to fill out, pre-certs to dictate and call in, and toenails waiting to be cut in the next room. I will let the profession decide which way to go when looking for a new paradigm of biomechanics, upgrading and expanding Root or Dr. Kirby’s.

Dennis Shavelson, DPM, NY, NY,



RE: Floroquinones and Tendon Injuries

From: Elliot Udell, DPM

The 12/1/08 issue of the Medical Letter reports that studies have shown that the incidence of injury after taking quinolone antimicrobials is from .14% to .4%. The risk is higher for patients over 60 years of age and those taking corticosteroids. The article went on to cite a case control study in Italy involving 22,194 cases non -traumatic tendonitis and 104,906 controls.

Relevant to podiatric medicine is the part of the study that reports Achilles tendon rupture occurred with fluroquinoline treatment in one of every 5,989 patents in general and one of every 1,638 patients who are over 60 years of age.

Elliot Udell, DPMHicksville,



RE: Orthotics and Bunions (Simon Young, DPM)

From: Dennis Shavelson, DPM

I would like to pose these theoretical questions:

1) If an orthotic could be dispensed that reduced functional hallux limitus and allowed peroneus longus to leverage and power to the point that it produced renewed stabilizing power upon the first ray, locking it more securely in closed chain with every step, would the IM, HAA and Met primus elevatus of that patient's pathological medial column improve?

2) Could manual therapy, motor control, and additional vaulting of the dynamic arches of the foot then leverage and power the flexor hallucis longus and abductor hallucis, further reducing the development or advancement of a bunion deformity?

Although Neoteric Biomechanics has not yet been double-blind studied, the podiatrists working with this new paradigm are doing just that, every day, in practice.

Disclaimer: Dr. Shavelson is the inventor of Neoteric Biomechanics and has a financial interest in the paradigm.

Dennis Shavelson, DPM, Medical Director, The FootHelpers Lab,



RE: CR vs. DR X-ray Systems (Mark K. Johnson, DPM)

From: Michael Fein, DPM, Marc Garfield, DPM

I have had a 20/20 DR System for over 2 years and I am very satisfied with the system and their service. Last summer, there was a power surge which unfortunately resulted in "frying" my DR system. I called Reina and had a new system in my office the next day before 11am. I have no financial relationship with 20/20.

Michael Fein, DPM, Bethel, CT,

From the standpoint of speed and functionality, the 20/20 NAOMI DR System works well. Resolution is better than plain films. Laterals and upright ankle films have a grainy appearance along the plantar-most soft tissue margin. This can be corrected with a 1-inch foam spacer under the foot, and by focusing the beam just over the foot rather than what one would do with standard film. Images are readable within 10 seconds from the time of exposure. Software is trouble-free.

The system can be used easily without an assistant as there is NO developing; it is essentially a big digital camera. Remember, even if the plates are digital, you can't take the next patient's films until you have cleared the films from the first patient. With the DR, I can take 10 views of both feet and not hesitate before filming the next patient.

20/20 is a great company to do business with. Tech support is unbelievable. I had a power outage and Cox changed my IP address in the same week. I didn't wait more than 20 seconds to have a tech help me re-establish network connections. They also included the setup/shipping and installation in their price quotes. Make sure you compare apples to apples.

Marc Garfield, DPM, Williamsburg, VA,



RE: CR vs. DR X-ray Systems (Eugene A. Batelli, DPM)

From: Multiple Responses

I was in shock to hear Drs. Eugene A. Batelli and DPM, Larry Kosova, DPM have had such problems with the DR X-ray system. My partner and I have had the unit since April and have had the best experience. We average 25-35 x-ray exams a day and have had excellent films. The speed is great, about 5-10 seconds, which is great for closed reductions of toes (I do it right on the x-ray stand).

The DR films have great clarity and only get "grainy" when I zoom in to very high magnification. The only problems I have had was when there is a Windows update. The computer needed to be restarted. The techs at 20/20 have responded both times in under 10 minutes and fixed the problem (Turn off the auto update). When the unit was installed the tech gave us his personal cell phone as well as the other technicians.

The company has been wonderful and the sales person calls once or twice a month just to "check up." It has been the best money I have spent in the practice. I have no financial relationship with 20/20. I’m just a very satisfied customer.

Timothy James Henne, DPM, Clermont, FL,

I have been using the 20/20 DR system for 5 months now, and have been very satisfied with the product and service that 20/20 provides. DICOM image picture quality is fantastic - better than any other I researched - without having to worry about cassettes and film. Upload time is about 30 seconds, just slightly longer than it takes to get the patient situated for the next x-ray. In the 5 months I have been using the system, I have not noticed any slowing of the system. Uploaded films can then be instantly viewed from any other computer on the network. MaS and kVp do not need to be changed because presets are a part of the system, and determined during set-up for each view. I purchased a used X-cel x-ray machine to use with the system and it has worked flawlessly.

Service from 20/20 has been excellent and very timely. Questions and problems have been minimal and have been solved quickly via either telephone conversation or remote access into my system. I have been very satisfied with the system, and 20/20’s service team.

Ryan Taylor, DPM, Heber City, UT,

I read Dr. Batelli's comments about his 20/20 CR and DR systems. I also have the 20/20 CR system. I agree with Dr. Batelli that the images are "crystal clear and the software is easy to use." I disagree with his concern about the 2 minutes to process the film. His unit is much slower than the current models. When taking x-rays with the newer 20/20 CR systems the slowest part of the procedure is positioning and taking the x-ray. The machine can process the film faster than you can position and take the next film. I know there are many podiatrists who are very happy with their 20/20 DR systems and know that 20/20 will make every effort to make all of their customers satisfied. There are currently more than 500 podiatrists using 20/20-Reina systems.

I have found 20/20 support to be excellent. I have not had my machine inoperable for more than 5 minutes in more than one year. My prior digital x-ray unit had to be replaced twice in the first 2 months; it was not a 20/20 or Reina unit. I welcome any calls or visitors to talk about digital x-rays. It was one of the top 5 ideas I have implemented in 30 years of practice.

Kenneth Meisler, DPM, Digital Imaging Consultant, 20/20 imaging,



RE: Painful Callused Heels (Shari Kaminsky, DPM)

From: Barry Mullen, DPM

I've read the prior postings and tend to agree that the etiology is likely repetitive, mechanical microtrauma from long-standing open back shoe wear. However, this individual is overweight and has a history of pre-existing autoimmune disease. Therefore, with this setting, I'd recommend ruling out hypothyroidism. Do a thyroid assay because a percentage of those patients may present with various forms of thyroid acropachy (affecting the skin and nails).

Locally, skin debridement with keratolytic ointment application under occulsion and rubber heel cups with closed back shoe wear generally helps. Systemically, your patient may be in need of thyroid supplements.

Barry Mullen, DPM, Hackettstown, NJ,



RE: 4th Ray Resection or Transmet? (Jeffrey Kass, DPM)

From: Multiple Respondents

I would do the TMA as a primary procedure. However, Dr. Kass's patient already has a BKA; so as an alternative option, in addition to a TAL and a 4th met. head resection, I would also resect the 2nd and 3rd met. heads in an attempt to equalize the length pattern and hopefully prevent further tissue breakdown.

S. Jeffrey Siegel, DPM, Philadelphia, PA, Heeldoc1@aol,com

A trans met with Achilles tendon lengthening would probably be your best bet. The patient will function well in a shoe with filler. I would maintain the metatarsal parabola and bias my cuts from dorsal distal to plantar proximal as to minimize the potential for further ulceration.

Gerald Mauriello Jr., DPM, MA, Toms River NJ,

Based upon Hx and clinical status, a proximal TMA, with well-contoured parabola and appropriate reduction of any distal osseous "spikes" would be my goal. The base of the 5th presumably has the peroneal insertion and medial soft tissue insertions are also assumed to be non-disrupted. TAL, immediate post-op bracing, rehabilitation and surveillance for contractures with Botox, and consideration for release residual deformity have been very positive for many of our patients in similar scenarios.

Alan Cantor, DPM, East Meadow, NY,



RE: Plate System for Osteotomy (Jason Serpe, DPM)

From: Dan Waldman, DPM, Paul Bassi, DPM

I have used Wright Medical's opening base wedge plate on a male mid-40's, marathon runner with great outcome radiographically and functionally. He is back to running without problems; of course the orthotics were part of the plan.

Dan Waldman, DPM, Asheville, NC,

I am quite familiar with the Wright Medical BOW plate and have done several opening wedge procedures using this system over the past 8 months. I agree with Dr. Weiner in that you have to be extremely careful when performing the osteotomy. It is very easy to be overly aggressive and crack through the lateral cortex, thereby creating a very unstable distal fragment. I typically go no further than 2/3rds of the way across with my cut and then attempt to open the wedge. I then press from lateral to medial at the hinge to open the osteotomy site for plate placement medially.

Patient selection is the key with this procedure. I have had excellent results with younger patients, some of whom I’ve done both feet about 8 weeks apart. Despite the osteotomy site being very stable with the plate in most cases, I still recommend a period of immobilization. Cast immobilization seems to work best, as the patients I have placed in CAM-walkers have begun ambulating prematurely despite my strict NWB instructions. I also use the Allomatrix as a bone filler and have had excellent results with it. My correction has been about 1.5 to 2 degrees per mm of wedge, and I have used the 3 mm. and 4 mm. plates in most cases.

Paul Bassi, DPM, Wichita, KS,



RE: Corticosporin Otic Suspension Discontinued (Richard Rettig, DPM)

From: Hal Ornstein, DPM

All the podiatrists in our practice stopped using Corticosporin otic solution when performing a matrixectomy several years ago due to the excellent results we got with use of AmeriGel wound dressing. It is much more convenient for the patient, with no soaking and once-a-day application. Outcomes are significantly improved with less redness, infections, pain and drainage. The Oakin in AmeriGel Wound Dressing provides the antimicrobial properties to fight off and kill the most common infections, and helps to remove debris. Amerx has packaged the AmeriGel nicely in a small box that includes gauze, Band-aids and wound wash. It is nice that we can add to the bottom line since Amerigel is not a prescription product and patients love that they save a trip to the pharmacy.

Hal Ornstein, DPM, Howell, NJ,



RE: Corticosporin Otic Suspension Discontinued (Richard Rettig, DPM)

From: Neil A Burrell, DPM, Joan Williams, DPM

My recommendation is to use Amerigel post-op. We are very pleased with the results, patients find it easy to use and it will add a little extra income at the end of the day. The manufacturer of Amerigel is also a big supporter of our profession.

Neil A Burrell, DPM, Beaumont, TX,

The brand I use is made by Bausch & Lomb, in Tampa, Florida. Neomycin and Polymyxin B Sulfates and Hydrocortisone Otic Solution. Each ml. contains: Neomycin sulfate equivalent to 3.5 mg Neomycin base, Polymyxin B sulfate equal to 10,000 Polymyxin B units, Hydrocortisone 10 mg. 1%

Joan Williams, DPM, Seattle VAMC,



RE: Mid-Arch and Met Pain (Kel Sherkin, DPM)

From: Philip H. Demp, DPM, MA, MS, PhD

Based on my published pilot study and an ongoing multi-research team funded by the NIH, the micromechanics of the metatarsal length pattern can be evaluated by a geometric configuration of the five metatarsal heads which corresponds to a unique equation. If this configuration turns out to be evaluated as a pathomechanical configuration, then shortening or lengthening by surgery or conservative therapy using the computer should produce precise information as to how to proceed in finding the appropriate toe(s) and amount to shorten or lengthen.

Surgeons are already doing this. However, in the literature, they talk about obtaining a parabola configuration, which is considered to be pathomechanical and may produce a clinical problem in the long run.

If you email me a weight-bearing, dorso-plantar radiograph, I will analyze it according to my research and send you a report by mail which includes possible treatment which you can consider. We assume that the problem was caused by a pathomechanical metatarsal length pattern.

Philip H. Demp, DPM, MA, MS, PhD, Cinnaminson, NJ,



RE: Monofiliments Not an Accurate Test of Neuropathy (Peter J. Bregman, DPM)

From: Allen Jacobs, DPM, Peter J. Bregman, DPM

PSSD is NOT the most sensitive means to detect small fiber neuropathy. Intraepidermal nerve fiber density testing is the most sensitive means to diagnose and quantitate small fiber neuropathy. PSSD remains contoversial and does have a CNS component. PSSD is not helpful for peripheral autonomic or motor neuropathy. IENFD testing may preceed positive EMG/NCV testing and PSSD testing for affirmartion of neuropathy by as much as 3-10 years.

The suggestion that retained 10 gram filament perception may be present in the presence of an ulceration is correct. That is why the examination should also include a 128 tuning fork, light touch, 2- point discrimination, reflexes, neuropad testing, manual muscle testing, questioning and observation. Small fiber neuropathy and large fiber neuropathy may cause symptoms without demonstrable office examination findings.

According to the guidlines of the ADA (January 2008-Diabetes Care), diabetic neuropathy can be diagnosed in 87% of cases WITHOUT the need for advanced diagnostic testing.

Allen Jacobs, DPM, St. Louis, MO,

Editor’s note: Dr. Bregman’s extended=length response can be read at:



RE: Monofiliments Not An Accurate Test of Neuropathy (Peter J. Bregman, DPM)

From: Lee Rogers, DPM, James J DiResta, DPM,MPH,

Dr. Bregman's opinion is fundamentally flawed. The 5.07 monofilament is not advocated to diagnose neuropathy, but to diagnose loss of protective sensation (LOPS) from neuropathy. Also, it depends on the location and number of sites tested to produce the correct result. The monofilament test has been proven in many trials to predict ulceration in patients with diabetes. The PSSD machine is not an accepted method to diagnose neuropathy or loss of protective sensation. It is a proprietary instrument that costs 10's of thousands of dollars, versus pennies for a monofilament.

There is a steep operator learning curve for the PSSD and it does not correlate with the most objective neurological test, the EMG/NCV. Furthermore, the PSSD is popular to determine the need and effectiveness of surgical nerve decompression in diabetes. Both the American Academy of Neurology(1) and the American Diabetes Association(2) have recently published position statements refuting the surgery as an effective treatment for diabetic neuropathy. There has only been 1 prospective trial of nerve decompression surgery at Grade IV (low level) evidence. The monofilament is not dead, it is alive and well. The combination of a monofilament test with a vibratory perception threshold (VPT) from a biothesiometer is more sensitive at detecting LOPS.

1. Cornblath DR, Vinik A, Feldman E, Boulton AJM. Surgical decompression for diabetic sensorimotor polyneuropathy. Diabetes Care 2007;30:421-422

2. Chaudhry V, Stevens JC, Kincaid J, So YT. Practice advisory: Utility of surgical decompression for the treatment of diabetic neuropathy: report of the American Academy of Neurology. Neurology 2006;66:1805-1808

Lee Rogers, DPM, Des Moines, IL,

I felt compelled to respond to the recent comments of Dr. Peter Bregman on PSSD testing as a better screening tool for peripheral neuropathy. In his comments, he infers that this is the new "gold standard" in diagnosing peripheral neuropathy which is a dangerous assumption. While it is true that PSSD is a highly sensitive test and therefore more likely to "capture" more patients with neuropathy, it lacks specificity, thereby finding many false positives and potentially labeling sick people as "sicker" when they are truly not at any more risk. The added danger of the so-called "potential benefit" of finding patients for "early" surgical intervention with surgical decompression based on this testing is also disturbing.

For us, as our country's leading foot healthcare providers, to promote such an algorithm of care with PSSD, a costly test compared with the simple and inexpensive monofilament testing in the process of screening for peripheral neuropathy is not the new standard of care. There is truly minimal gain and potential harm with PSSD use as a screening tool which is just not supported by the present literature and cannot justify the cost to our healthcare system at this time. Use of PSSD testing is for pre-surgical assessment and even at that, questionable, as it promotes intervention in a manner that is still in dispute.

James J DiResta, DPM, MPH, Newburyport, MA,



RE: Monofiliments Not An Accurate Test of Neuropathy

From: Peter J. Bregman, DPM

It has been shown that the earliest indication for loss of ulcer threshold for the foot is around 4.3gms/mm2. The typical 5.07 monofilament only bends around 66gms/mm2, thus this "gold standard" simple test is not an accurate test, especially if trying to detect the earliest signs of neuropathy. If you don't think this is true, please use the filament on a few patients who already have ulcers and try it out. You will find they can still have a 5.07 monofilament positive test.

The PSSD machine is the best and most sensitive tool for detecting neuropathy. The reason I post this response is to hopefully alert the people who are still using this outdated means of testing to at least be aware of how inaccurate and crude the monofilament is. It is also not an exacting test; it is just a range of measurement.

Peter J. Bregman, DPM, Tewksbury, MA,



RE: Weil Osteotomy w Cheilectomy (Stuart W. Kushel, DPM)

From: Lowell Weil, Sr., DPM, Greg Caringi, DPM

When treating hallux rigidus, one must consider the different forms and degrees of the deformity prior to choosing a "favorite procedure". While the Weil osteotomy may have value in some cases of hallux rigidus (Malerba - Foot & Ankle International 9/2008), the cheilectomy with a Moberg (we have done this for years and called it a Bonney & Kessel) has had favorable results as reported by Coughlin in long-term studies. Finally, implant arthroplasty and arthrodesis have their place as well depending on the degree of deformity. So, let us not recommend our "favorite operation" without discussing in detail when it should be performed. Surgeries have much better results when they are performed for the proper criteria.

Lowell Weil, Sr., DPM, Des Plaines, IL,

I have used both the Youngswick modification of the Austin procedure and the Green modification of the Watermann procedure in combination with cheilectomy & subchondral drilling with good results. As far as first met shortening, I always follow a simple principle that I learned from Dr. G. LaPorta many years ago at one of the original Hershey conferences -- always plantar-flex (or plantarly displace) the first met head an equal amount relative to the 1st met shortening. Shortening is highly desirable for decompression of hallux limitus. If you can plantar-flex in equal measure, the first ray will remain stable and functional. This all within reason, of course.

Greg Caringi, DPM, Lansdale, PA,



RE: Arthrosurface Hemi Cap for Frieberg’s Infraction.( William Sachs, DPM)

From: Alan MacGill, DPM, Jeffrey Kass, DPM

Arthrosurface makes a larger implant (15 mm.), which is commonly used to resurface the first metatarsal, and a smaller size (12 mm.), which is what we have used to resurface the second metatarsal. The 12 mm. implant has worked great to re-establish a congruent articular face, all while maintaining the weight-bearing surface of the metatarsal.

We've performed this procedure in 4 cases. All cases involved the 2nd metatarsal and the patient age ranged from 29 to 68. Our follow-up has ranged from 10-19 months in this small sample size but results have been good. All patients have had increased joint range of motion, decreased levels of pain, and a return to desired activity level. These results have been promising but we'll have to wait and see how these implants hold up long-term.

Alan MacGill, DPM, Orlando, FL,

I just recently had a discussion with a fellow colleague regarding this type of case. The thought for this type of procedure is that you have a damaged met head and the implant would take its place. The con is the met head is collapsing, this is the disorder. So, the concern would be whether or not the implant can hold due to the decreased strength and collapsing nature of the bone. I have not done a literature search on the topic, but decided the con was too much of a concern.

Jeffrey Kass, DPM
, Forest Hills, NY,



RE: Weil Osteotomy w Cheilectomy (Stuart W. Kushel, DPM)

From: Daniel J. Tucker, DPM, Sloan Gordon, DPM

I have found that shortening the first metatarsal can lead to unwanted problematic ramifications. I have been utilizing the Moberg type proximal phalangeal osteotomy in patients with hallux rigidus and a well-preserved 1st metatarsal articular surface (well- described in the orthopedic literature) for a number of years now with very good results. The premise of the procedure involves "borrowing from Peter to pay Paul." The axis of rotation of the hallux at the 1st MTP joint is moved more dorsally so that dorsi-flexion is increased at the expense of some plantar-flexion. The joint is decompressed as well. If there is adaptive hallux interphalangeus, the osteotomy can be adjusted in a "bicorrectional" manner to allow for reduction to a more rectus position.

If the 1st metatarsal head has significant erosive change but the phalangeal base is preserved and the sesamoids functional, I have been resurfacing the head with an Arthrosurface implant, again with improved motion, joint decompression and pain reduction. Since only the remaining cartilage and a small amount of subchondral bone are resected, future salvage fusion, if required, is not difficult since no bridges are burned. This is in contrast to the more traditional implants that have been fraught with complications over the years.

Daniel J. Tucker, DPM, Newport Beach, CA,

I have been using a technique which works very well for hallux limitus/rigidus to shorten the first ray. I use two blades on an oscillating saw and make a fairly aggressive chevron cut, plantar-flexing the first ray and shortening it. This has worked very well for my patients. I fixate with two modular hand screws (Synthes), allow immediate weight-bearing in a fracture CAM boot, and find it relatively simple to do (although I recommend practicing with saw bones or cadaver bone first.)

I have not tried the Weil for first ray deformities, although it's my favorite for lesser metatarsals, and when accompanied with an MTF 2.0 bone pin for fixation, is quite simple and easy to fixate. I would consider a Weil for the first. In addition, I'm just starting to do the Arthrosurface procedure and hopefully that will work as well for the foot as it has for the hip & knee and should make for shorter healing time.

Sloan Gordon, DPM, Houston, TX,


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