Podiatry hocus pocus, lotions and potions, lies and shenanigans

[heybrother]

What works. What doesn't. Garbage people peddle. Real things we've ruined. Better ways to do things.

I have more to say, but wanted to just get this started after Bako came up.

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[heybrother]

Do you believe in any topical nail related anti-fungal

Formula-7
Formula-3
Tolcylen
Higher strength Urea - 40-46%?

 

[CutsWithFury]

Do you believe in any topical nail related anti-fungal

Formula-7
Formula-3
Tolcylen
Higher strength Urea - 40-46%?

It’s either Penlac or Jublia for topicals for me. But most patients have done and failed these so I’ll do lamisil with lab testing prior to giving the meds and at 6 weeks. Treat with 3 months worth of anti fungals

 

[josebiwasabi]

Lamisil before and at 6 weeks for l good candidates

Otherwise tolcylen solution for the topical crowd +/- Clearanail procedure (microperforations of the nail plate). Personally I have never seen penlac work.

 

[CutsWithFury]

Lamisil before and at 6 weeks for l good candidates

Otherwise tolcylen solution for the topical crowd +/- Clearanail procedure (microperforations of the nail plate). Personally I have never seen penlac work.

Penlac doesn’t. But give them something to get out of my office.

Clearanail procedure? That’s some DPM hocus pocus

 

[DYK343]

I dont sell anything out of my office. I refuse to. Seems so scammy and greasy. (que practice management guys in 3... 2... 1...)

I tell them they can pay big $$$ for Jublia with <20% cure rate.

I inform them cheaper versions like Penlac are available but it also wont work.

I dont do lazer therapy because I dont think it works and I watched a lot of providers make some serious, IMO fraudulent, cash. But I give them the option for a referral for cash pay laser.

I tell them the best method is oral terbinafine. I test the liver once and if they want a refill I test again. Not too worried about the liver and there is literature (test only once) to back that up.

I have about 75% success with oral terbinafine. I have maybe seen 1-2 people get better with topical.

I dont send nail samples to a lab. There is 1 insurance company that gives me a hard time in which the patients pay the $10 a month for the medication. I feel the lab comes back negative too much. If it comes back negative and you give them oral antifungals they commonly get better. So I dont order the lab. Waste of $ IMO.

 

[josebiwasabi]

Penlac doesn’t. But give them something to get out of my office.

Clearanail procedure? That’s some DPM hocus pocus

In 1 year I've only had 2 pts do the clearanail, but both actually had improvement. The theory makes sense though, since it allows the topical medication to actually get under the nail plate.

I offer it to patients who have been around the block and have already tried all sorts of other treatments without results, because at that point the only other options are to live with it or to have a nail avulsion.

Lamisil is always my first choice if they are a candidate.

 

[CutsWithFury]

In 1 year I've only had 2 pts do the clearanail, but both actually had improvement. The theory makes sense though, since it allows the topical medication to actually get under the nail plate.

I offer it to patients who have been around the block and have already tried all sorts of other treatments without results, because at that point the only other options are to live with it or to have a nail avulsion.

Lamisil is always my first choice if they are a candidate.

I don't get it. Why not remove the nail entirely and have them put the topic right under the proximal nail fold?

 

[air bud]

Young healthy why test labs? Waste of money they are fine. Also ALT can be 2x before need to worry. Older I may do labs once but again if no history of disease no reason to test twice. If serious fungus I won't give, tell them to live with it. Mild to moderate I say may work, 70 percent effective. The most important thing is to educate them on how it works. Take a pic today, in one month, in two months etc...don't think about seeing results for a leat three. Don't come to me until 6 months to complain it didn't work. No laser. Fortunately where I live nobody paints there nails or wears sandals to look good.

Orthotics. 99 percent do great with powersteps. True deformity gets custom from orthotist who knows what they are doing.

Manual muscle testing - scam

Balance braces - scam

Genetic testing - scam

Antibiotic foot baths - scam

In office shoes....there is literally not a place within 3 hours of me to buy shoes not at a Walmart. I am actually trying to figure out how to carry vionic/Birkenstock or something along those lines.

Hokas - scam. (Not really...) Asics/powersteps fixes everyone's problems. Get the style guide from a few years ago not the new one, does a better job of showing them categories. Go on to Amazon and get last year's model for half the price. Flat - gt2000 literally every person lives them. High? I think it's the cumulus but may be wrong.

Anything that is not stretching, not going barefoot (Burks/vionic sandals for the house) is a scam. Steroid injections obviously too. Night splints? Everyone hates them and doesn't use them and gets crappy sleep even if they work. Tell patient but make buy on their own.

Pain on met bases? Surgical shoe 50k units vd3 once a week for 6 weeks no labs see you in 3 weeks.

Big heal callus? 15 dollar 40 percent urea cream on Amazon, not that Blain labs **** this isn't 2012.

Nutraceuticals - scam

Anything you sell in your office besides some basic OTC orthotics, crest pads, toe spacers etc. - scam

Pain, no recent trauma to decrease healing process? Boot and medrol dosepack. Steroids fix everything. Wear the boot while sleeping when on steroids.

These are real people. With real bills to pay. I live in a tiny ( you have no idea...) Town. These are my neighbors, I see them at the grocery store, at the gym, at the baseball game. Much of the problem is that in big cities you never see these people outside of the office. Just a blank checkbook to you. What can you get them/insurance to pay.

There you go new grads/3rd years you know how to deal with 75 percent of patients. Thanks for coming to my TED talk.

 

[PeaJay]

Young healthy why test labs? Waste of money they are fine. Also ALT can be 2x before need to worry. Older I may do labs once but again if no history of disease no reason to test twice. If serious fungus I won't give, tell them to live with it. Mild to moderate I say may work, 70 percent effective. The most important thing is to educate them on how it works. Take a pic today, in one month, in two months etc...don't think about seeing results for a leat three. Don't come to me until 6 months to complain it didn't work. No laser. Fortunately where I live nobody paints there nails or wears sandals to look good.

Orthotics. 99 percent do great with powersteps. True deformity gets custom from orthotist who knows what they are doing.

Manual muscle testing - scam

Balance braces - scam

Genetic testing - scam

Antibiotic foot baths - scam

In office shoes....there is literally not a place within 3 hours of me to buy shoes not at a Walmart. I am actually trying to figure out how to carry vionic/Birkenstock or something along those lines.

Hokas - scam. (Not really...) Asics/powersteps fixes everyone's problems. Get the style guide from a few years ago not the new one, does a better job of showing them categories. Go on to Amazon and get last year's model for half the price. Flat - gt2000 literally every person lives them. High? I think it's the cumulus but may be wrong.

Anything that is not stretching, not going barefoot (Burks/vionic sandals for the house) is a scam. Steroid injections obviously too. Night splints? Everyone hates them and doesn't use them and gets crappy sleep even if they work. Tell patient but make buy on their own.

Pain on met bases? Surgical shoe 50k units vd3 once a week for 6 weeks no labs see you in 3 weeks.

Big heal callus? 15 dollar 40 percent urea cream on Amazon, not that Blain labs **** this isn't 2012.

Nutraceuticals - scam

Anything you sell in your office besides some basic OTC orthotics, crest pads, toe spacers etc. - scam

Pain, no recent trauma to decrease healing process? Boot and medrol dosepack. Steroids fix everything. Wear the boot while sleeping when on steroids.

These are real people. With real bills to pay. I live in a tiny ( you have no idea...) Town. These are my neighbors, I see them at the grocery store, at the gym, at the baseball game. Much of the problem is that in big cities you never see these people outside of the office. Just a blank checkbook to you. What can you get them/insurance to pay.

There you go new grads/3rd years you know how to deal with 75 percent of patients. Thanks for coming to my TED talk.

This is pure gold...We practice with similar styles. I also live/work in a rural setting and there is no tolerance for experimentation or doing unproven treatments/surgery on a Neighbor.

 

[G0dFather]

Young healthy why test labs? Waste of money they are fine. Also ALT can be 2x before need to worry. Older I may do labs once but again if no history of disease no reason to test twice. If serious fungus I won't give, tell them to live with it. Mild to moderate I say may work, 70 percent effective. The most important thing is to educate them on how it works. Take a pic today, in one month, in two months etc...don't think about seeing results for a leat three. Don't come to me until 6 months to complain it didn't work. No laser. Fortunately where I live nobody paints there nails or wears sandals to look good.

Orthotics. 99 percent do great with powersteps. True deformity gets custom from orthotist who knows what they are doing.

Manual muscle testing - scam

Balance braces - scam

Genetic testing - scam

Antibiotic foot baths - scam

In office shoes....there is literally not a place within 3 hours of me to buy shoes not at a Walmart. I am actually trying to figure out how to carry vionic/Birkenstock or something along those lines.

Hokas - scam. (Not really...) Asics/powersteps fixes everyone's problems. Get the style guide from a few years ago not the new one, does a better job of showing them categories. Go on to Amazon and get last year's model for half the price. Flat - gt2000 literally every person lives them. High? I think it's the cumulus but may be wrong.

Anything that is not stretching, not going barefoot (Burks/vionic sandals for the house) is a scam. Steroid injections obviously too. Night splints? Everyone hates them and doesn't use them and gets crappy sleep even if they work. Tell patient but make buy on their own.

Pain on met bases? Surgical shoe 50k units vd3 once a week for 6 weeks no labs see you in 3 weeks.

Big heal callus? 15 dollar 40 percent urea cream on Amazon, not that Blain labs **** this isn't 2012.

Nutraceuticals - scam

Anything you sell in your office besides some basic OTC orthotics, crest pads, toe spacers etc. - scam

Pain, no recent trauma to decrease healing process? Boot and medrol dosepack. Steroids fix everything. Wear the boot while sleeping when on steroids.

These are real people. With real bills to pay. I live in a tiny ( you have no idea...) Town. These are my neighbors, I see them at the grocery store, at the gym, at the baseball game. Much of the problem is that in big cities you never see these people outside of the office. Just a blank checkbook to you. What can you get them/insurance to pay.

There you go new grads/3rd years you know how to deal with 75 percent of patients. Thanks for coming to my TED talk.

THIS IS PRETTY MUCH PODIATRY!! plus the RFC!! ... 7-8 years condensed into this post LOL ( which shows how much of a joke all that time is, hence the push for SURGERY by the profession) ... when people find out about this its easy to see why we arent taken serious ... can anyone find a similar breakdown of real day to day stuff in other MD professions, i dont think it will come close to this clown town stuff ? .... That being said if one can figure out how to make the above streamlined and very profitable then it becomes a Kush low risk profession with chill day to day stuff, sad but true

 

[heybrother]

Sooooo many things to reply to.

Terbinafine - Almost never prescribed in residency. My impression from reading about it more since getting - overall safe medication and there's quite a bit of cost analysis stuff out there saying almost all testing is overdoing it. Efficacy is highly variable and plenty of people aren't going to get better no matter what we do. I check liver (AST/ALT and yeah, there are more labs that could be done that probably just add to the bill). I've been pulse dosing lately. 1 week on, 3 weeks off. I'm moving towards only liver testing at the beginning if I pulse dose. Write for 4 months and follow-up at 4-5 months. The PCPs/internists in my area will keep a patient on it forever and while I have patients tell me their PCP already told them they had elevated liver enzymes I have other people who don't recall ever being tested (though perhaps they had some prior panel that they made the judgement on). The MDs honestly ...leniency towards its use has made me feel better about using it. I do explore people's alcohol use and I won't write for daily drinkers.

Penlac/Cyclopirox. Used this in residency. I seem to recall the success rate is like 6% and obviously success rate can mean many things. The first time I prescribed this at my current job insurance rejected it and told me to prescribe terbinafine. Jokingly, its not often an insurance company gives you good advice.

Tolcylen/Formula 3 / Formula 7. I don't think there's any evidence out there about these. Like you can't find a study. Supposedly Tetra gives a guarantee/money back on the Formula crap. Somewhere out there is some generic I guess lab related stuff where people tried to demonstrate that tolnaftate/urea/whatever oils are used can soften/increase penetration/whatever of nails. We sell these for an almost no margin mark-up - like less than $35 for 3 or 7. I think we're paying $20 or something for them. Tolcylen on the other hand is expensive to purchase for a practice. My motivation for "dispensing" this is practice management, but its not practice management making money on the cream. Its just getting out of the room. I've had too many people that I essentially told them - there's nothing that's going to work, or they won't take terbinafine, or whatever. And at the end of this talk they won't give it up - like I'm holding something back from them. Having a topical (that I tell them won't work) gave me a way to say - here, try this - we're both in agreement this is what you'll try. I'm trying to never have one of those encounters where I just say - I'm sorry, but I'm walking out now, I've told you everything I can tell you. I'm not bothered by people asking about treating nail fungus - it sucks - especially for young women. I just want to have controlled efficient encounters. I do not require follow-up to get more nail cream. Buy it a the front desk to your heart's content if you think its working.

I usually recommend breaking up the top surface of the nail/thinning it with an emory board regularly which I guess is a cheaper patient directed version of the clearnail which apparently costs like $500 though I suppose it costs whatever the pod wants to charge since it isn't going to be covered by insurance. Perhaps they could come back repeatedly! 11730 seems to be worth about $160 to BCBS. Seems like clearanail is then followed by some sort of topical therapy afterwards - I suppose that's then DPM directed based on whatever you are selling in the office.

I haven't seen anyone follow-up up for it yet, but I've had a few people where I avulsed the nail and then started them on pulsed terbinafine + apply a topical the second the nail returns to try and have the nail under therapy the entire time the nail is growing. Avulsing a nail that is fungal and doing nothing essentially always results in the same nail they had before therapy.

Airbud's stuff
-Fungus - Yeah, tell them to set realistic expectations. There are studies of terbinafine where the efficacy is way less than 70%. Some of the studies have been done in VAs though and those are obviously wonderful places to work with their Vietnam fungus and what not.
-Agreed - take a picture cause neither you nor the patient will have any real memory of what it looked like. I had some people where we did whatever therapy - ie. topicals and I brought them back at 2-3 months to look again - and I can't tell a god damn thing. No point bringing them back early at all. I've told some people 5 months above and I wonder if I'll regret it ie. too soon.
-I've had a few people tell me they were making good progress and then they stopped and it immediately recurred. If something is happening I suppose I'll try and see it through to whatever degree of normal they can get for the whole nail.

Laser - if laser worked every single dermatologist/family medicine group would have one. That podiatry is the number one pusher of this in the community tells me something. Weirdly, I had a patient come from another DPM who does laser and he told her it wouldn't work - seemed like bad onycho to me - found myself wondering - a guy with a laser and a conscious - what gives.

Off topic - pain laser. We have one. I haven't sent a single patient to it. Maybe I'm missing out. Last person I saw who had been using it had SEVERE vascular disease when I sent him off to cardiology for testing which hadn't been done/documented/etc.

I trained in an isolate area. We had a nice shoe store, but nothing else was available. We carried an in office orthotic - nothing else in town carried/sold them- switched it around a few times. Think Prolab P3 and then some other similar looking different varieties later. It was very affordable when I started and it kept going up in price by the time I left. Perhaps the manufacturer increased the price. Everyone got stretching + choose shoe or choose orthotic or both or I guess neither + medication. For the vast, vast, vast majority of people this was all that was ever needed. More on that later. As the price went up I did feel like there were more patients who were burdened/couldn't afford it

Orthotics.
Where I am You can buy a nice Spenco in my area for $22. Another stores sells Powersteps/2 different Spenco variations for sub-$30. They do perfectly fine. My partner builds them up with all sorts of padding and crap. Its not necessary at all. Interestingly, I don't really think a decent Spenco wears out. I've seen a lot of people through the years with a well built "rigid OTC"/Spenco/whatever asking do they need a new orthotic and I think the answer is almost always no.. I'm going to add a "OTC" product from a manufacturer for $45-50 that will look custom. Similar to residency. Yes, there's a money component, but the margin is going to be sub-$30 and its going to affect room turn over. My other consideration is the store I was sending people to was constantly sold out and then shut down through the pandemic. I kept having telehealth encounters for plantar fasciitis where people would ask me - don't you have anything in your office. So we're going to. Eventually.

Customs - I've sold zero customs this past year. My practice charges $500 which is highway robbery though amusingly the Good Feet store routinely dings people for $400-1400 for literally non-custom crap. My residency sold for $350 (rarely) and one of my competitors sells for $350 also. My ultimate goal - get a 3D-scanner and then undercut the hell out of everyone in the area. Like ...$200 bucks for a pair of customs. The manufacturer I used in residency had a unit cost of like $60ish. If they are so great and so necessary they should be easier/cheaper to get and it isn't time consuming to scan. There won't be plaster. There won't be shipping. I don't believe in them, but if I "have" to do it I just want it to be easy. I also don't want to deal with the "fussing" bullcrap that comes with many of them. I'll only send them off for straight forward flexible flatfeet/no real deformity people and I'll set low expectations. If you charge someone $500 it better be awesome. If someone's issue is pressure/prominence/ulceration/things that require fiddling/adjusting/moving - I have an awesome pedorthist in the area who for people I carefully select he resolves the issue every single time. He's literally made a bunch of easy accomodatives for people for like $100ish bucks and I don't have to mess with 'em or take complaints or cut or whittle. If you make something you are responsible for it.

Kid stuff - I'm going to get one of those Pedrings for OTC kid orthotics. The majority of kids don't need anything (and I sat through a presentation from that douchebag in the NE who runs the peds organization and scaretactics every single family he meets with his kiddieline etc) but I do have flatfoot kids who are still in pain after the easy stuff - its really just an option and its going to be a $50 option as opposed to a custom that they'll grow out of. I cringe when a parent comes in with a growing kid and says - he had very expensive customs he outgrew. You can buy individual kid UCBL style "OTCs" for $20 a pair. I won't keep these in the office. I'll just fit and order.

What is this genetic testing you speak of. haha. My god. Presumably this is for nail related crap, but if this is something more I need to know.

Shoes - I give a list that basically says Brooks / New Balance / Hoka / Asics. Yeah, Vionics isn't a bad dress/shoe flat though I don't particularly care for the rest of their line. If you tell me you are hurting that much I'd just as soon you'd wear a tennis shoe for awhile and yes, its frustrating being a woman who needs to dress up for work and has foot pain. There's definitely a price spectrum across these and I think anything can work. I'm literally wearing the cheapest shoes Brooks sells and they are one of the most comfortable I've ever had. Best part of a shoe list - when someone shows up with a bag of shoes you can point at your list and say "these are the only things I recommend." JK. Good luck. That person is usually ill. There's a nice shoe store in my area that sells everything, but I think they talk a lot of crap and mumbo jumbo telling people this and that shoe is the shoe for them or this is a plantar fasciitis shoe. Anyone can get better in any adequate shoe. Hell they can get better without a shoe. I've had a few people show up in a shoe they hated and they told me the shoe store person assured them it was the shoe for them.

Stretching. Free. For essentially everyone.

Night Splint. Agreed. They don't work. The number of patients who have told me "I fall asleep with it on and then wake up 30 minutes later and throw it across the room". Almost no one can tolerate them. They can be purchased on Amazon for like $20ish dollars. Wonder how much they cost in a pod's office.

Injections. I'm not bothered by them and I'm always interested to hear about regional variations in practice. There's an F&A ortho in my area who doesn't do them at all and ...puts everyone in a CAM boot for 6 weeks. Unless I'm missing something they pay the same or less as a level 3 visit which I probably won't be charging for so I don't think I'm doing something obnoxious from a billing standpoint. I don't think they work in isolation. I have plenty of people who already were injected by their FM with no improvement and I immediately offer them the easy conservative things they haven't done and should have done first. I'll only give 2 at the beginning of therapy (3 weeks apart) and the next would need to be forever away. I inject half of what I was injecting in residency and I'd say I have better effect now - which probably says something about my patient population. I inject medially and I redirect/needle/try and inject above/through/below. Plenty of people don't need them and I never give anyone crap if they refuse. Again, the goal is pleasant, smooth, no-awkward encounters. I don't hold back or dole out - all my conservative stuff is offered at once.

I do inject the STJ through the sinus tarsi. That seems to be uncommon in some areas. It is way less painful than the plantar fascial injection. Do I think plantar fascial injections work - I've had positive experiences with them though I'm also willing to admit that I think anything can resolve with time and with minimalist therapy. Hell - people get better with just stretching. Its a minimalist therapy compared to surgery. I've had a few people recently who did 2 years of PT/chiropractor therapy for unending pain that resolved with a shot. I don't believe in anecdotes, but it was pleasant to offer something that had never been offered or tried and have it work.

Urea - agreed. Its great. If you try and prescribe 40% through a pharmacy you'll get an angry patient... like $100+ prescription. $15-20 through Amazon. I wish I had a way to sell it somewhere around there because a lot of people in my area won't bother going on Amazon to buy it. Compliance is frustrating if you ask a patient to lift a finger. We carry 46% urea for nails. It will break down a big crumbly nail. We sell for $25 so obviously we are more expensive than Amazon.

Don't know anything about nutraceutical. I've had patients ask for Metanax lately and a WHC FM doc tell me it was amazing. My partner thinks its overpriced crap. Its at least $60 a month.

I like medrol (dosepack, 4 mg, 21 pills). We did medrol/naproxen in residency depending upon the patient. I saw a lot of people referred to us who were on Meloxicam and I initially thought it was crap. I've used it quite a bit since then and the issue was - "meloxicam + nothing" is as effective as medrol + nothing or whatever the referring doc prescribes + nothing. I don't think meloxicam is powerful, but for a lot of aches and issues its quite helpful and its so easy to dose at 1 pill a day. Any NSAID is going to have some complaints/issues/discontinues

I try to only use boots for fractures, things highly suspicious for fracture ie. focal bone pain fibular/metatarsal shaft pain+swelling, and sprains. Anything that is mechanical tissue strain ie. plantar fasciitis, Achilles tendonitis, "midfoot/medial strain", posterior tibial tendonitis, etc I try to walk/stretch them/stabilize them with stretching/shoe+/-insert/anti-inflammatory. Nothing worse than coming out of a boot and having the exact same problems. Boots seem to be a big profit maker in some places. You can buy a very nice boot for $50 but they end to selling in stores or practices for $150-250. Obviously a tidy profit if you see a lot of 5th metatarsal avulsion fractures.

Metatarsal bar - my partner pads everybody's orthotics up (grinding and gluing and what not). One of the pads he was using to me was a knock-off metatarsal bar ie. easy padding stuck to an orthotic behind the metatarsal head. He uses it to build up medially Doesn't look great, but way better tolerated than toe taping for capsulitis. I can't get anyone to admit they like toe taping for pre-dislocation. In other news, I took the ACFAS forefoot educational sheet on MPJ pain and re-wrote it. If the toe drifts at all the patient will need surgery? Bullcrap. Some of the unhappiest people in the world are people who have 2nd MPJ surgery.

Feel ya Godfather. So many people can quickly and easily be resolved with straightforward conservative stuff. Run low overhead. Have efficient encounters. The desperation, the pursuit of surgery, the unnecessary operations that don't work, pushing custom orthotics on everyone - its just stupidly draining. Awhile back a guy came to see me. Has the world's tiniest bunion + some mild 1st MPJ joint pain after a day on his feet. Was told elsewhere he needed either custom orthotics or some convoluted version of an austin. Told him shoes + stretching + meloxicam - he bought a Spenco and an Asic. Kayano maybe. I don't remember. 3 weeks later drove 2 hours to tell me it was awesome (...and to go out to eat). I got bitched out later that same day for not demanding more people do surgery. Still laughing in my mind about it.

Anyway. Would still love to hear about some more scams, things marketed on podiatry news, "podiatry focused/marketed" junk - like that Swyft pen for warts that all the people writing in praising are owners of. We should also do a "what surgeries work" thread. That should be a blood bath.

 

[dtrack22]

Night Splint. Agreed. They don't work. The number of patients who have told me "I fall asleep with it on and then wake up 30 minutes later and throw it across the room". Almost no one can tolerate them. They can be purchased on Amazon for like $20ish dollars. Wonder how much they cost in a pod's office.

Insurance pays around $120-140 for a night splint...so you can assume any pod office charges around $70-90 for one. The last office I was at charged around $85 I believe. I dispensed them after my night splint talk. Which was basically, “nobody I know can sleep in this and therefore it is no better than just doing the stretching I told you to do. BUT if you know you are someone who isn’t going to stretch on your own, and you want an easy and idiot proof way to do gastroc stretches while you watch tv at night, this might help.” I told people not to wear it for more than 30 min and to use it several times a day. Basically the only patients who got it were those who were very honest about how lazy they were, or those who had met their deductible and the splint was going to be covered at 100%


is the swyft thing the microwave treatment? Because the microwave stuff is incredibly dumb. It’s not covered by insurance. The tip costs you money every time you use it. The machine costs you money. They say it takes 3-4 treatments. And all along canthrone is cheap, takes the same number of treatments and is covered by insurance. Of course they can’t get many dermatologists to use it (they still use liquid nitrogen), only the dpms are dumb enough to needlessly jack up their own overhead.

There’s a saying in the medical device sales world about new products and podiatrists...I’ve found it to be unfortunately accurate

 

[heybrother]

It is indeed - for some reason I remembered it spelled wrong - it is Swift. I added cantharone after the wart thread. I did cryo in residency for warts and I prefer this. I figured it would be thicker or more gelatinous. Its not - makes me think we're going to have a ton of applications out of 1 bottle which cost a little bit more than $100. But yeah - I am a podiatrist, so I should push to buy something expensive, like our pain laser. And its not even like a hand held pain laser. Its literally this large machine with wheels. That takes up a corner in one of our procedure rooms. #podiatry!


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[heybrother]

Messing with their calculator on the lease function - if price is set to $249 (for presumed 3 applications), assume 1 new patient a year, they indicate your 5 year profit is $148. Charging $249 x 52 x 5 = $64592. Subtract 148 and divide by 5 and the rough lease/equipment cost is about $13000 for a year and 156 tips.

Purchase - if price is $237 it takes 258 weeks to make a profit which means the price is about $60-61K for the device and the equipment to use up to that point.

What's the real purpose of this. Its not to help people. Its to have a device that isn't covered by insurance so you can charge them whatever. You do the podiatry shenanigan pitch - those other therapies don't work. They hurt. This is pain-free and amazing. No blisters. No cryo! But no, its not covered by insurance so pay $big dollars. It isn't like you'll tell people - oh that's an easy or a small wart. You'll use it on everything. Cause you have to. Cause you owe that company a fortune. Or you can use cantharone. The bottle is $100 bucks + shipping. BCBS PPO pays $170 an application. No $13000 lease required.

 

[Pronation]

That stupid in office arterial Doppler crap that amazingly insurance reimburses podiatrists for so they abuse it and test everybody that comes through the door. You could put that thing on a dead person and it may detect pulses.

 

[air bud]

Last couple of posts demonstrate a great lesson : If you have to talk people into it to pay it off, you are an idiot. It's like the rule about money and friends. If you can't afford to let it break/expire don't buy it.

You can't get around these ridiculous rents in these terrible big cities. So at least don't do other stupid stuff to make overhead so high.

 

[air bud]

Also I repeat balance braces are a scam and you suck if your prescribe them

 

[deleted285117]

Young healthy why test labs? Waste of money they are fine. Also ALT can be 2x before need to worry. Older I may do labs once but again if no history of disease no reason to test twice. If serious fungus I won't give, tell them to live with it. Mild to moderate I say may work, 70 percent effective. The most important thing is to educate them on how it works. Take a pic today, in one month, in two months etc...don't think about seeing results for a leat three. Don't come to me until 6 months to complain it didn't work. No laser. Fortunately where I live nobody paints there nails or wears sandals to look good.

Orthotics. 99 percent do great with powersteps. True deformity gets custom from orthotist who knows what they are doing.

Manual muscle testing - scam

Balance braces - scam

Genetic testing - scam

Antibiotic foot baths - scam

In office shoes....there is literally not a place within 3 hours of me to buy shoes not at a Walmart. I am actually trying to figure out how to carry vionic/Birkenstock or something along those lines.

Hokas - scam. (Not really...) Asics/powersteps fixes everyone's problems. Get the style guide from a few years ago not the new one, does a better job of showing them categories. Go on to Amazon and get last year's model for half the price. Flat - gt2000 literally every person lives them. High? I think it's the cumulus but may be wrong.

Anything that is not stretching, not going barefoot (Burks/vionic sandals for the house) is a scam. Steroid injections obviously too. Night splints? Everyone hates them and doesn't use them and gets crappy sleep even if they work. Tell patient but make buy on their own.

Pain on met bases? Surgical shoe 50k units vd3 once a week for 6 weeks no labs see you in 3 weeks.

Big heal callus? 15 dollar 40 percent urea cream on Amazon, not that Blain labs **** this isn't 2012.

Nutraceuticals - scam

Anything you sell in your office besides some basic OTC orthotics, crest pads, toe spacers etc. - scam

Pain, no recent trauma to decrease healing process? Boot and medrol dosepack. Steroids fix everything. Wear the boot while sleeping when on steroids.

These are real people. With real bills to pay. I live in a tiny ( you have no idea...) Town. These are my neighbors, I see them at the grocery store, at the gym, at the baseball game. Much of the problem is that in big cities you never see these people outside of the office. Just a blank checkbook to you. What can you get them/insurance to pay.

There you go new grads/3rd years you know how to deal with 75 percent of patients. Thanks for coming to my TED talk.

I agree 100%. When practicing medicine you gotta be practical; as a personal rule, I usually don’t recommend items that I probably wouldnt pay for myself. Patients appreciate it. Don’t be a shyster.

Additional thoughts:

Orthotics - Powersteps are great. Another great option is Spenco Orthotic Arch orthotics ($30 on amazon).

Amen on the urea. I also tell patients to buy 40% online. That, or I give them Kerasal cream coupon (you can get this off their website for free).

Orthotics - for sure send any custom orthotics/bracing to someone who does it for a living and has a workshop to make modifications... orthotist!

Onycho - I tell pts any topical (OTC or Rx) 25% cure, Diflucan 50% cure, Lamisil 75%. If fungus been there for > 5 years or looks terribly dystrophic I tell them to go with softeners (Kerasal lacquer - coupon also online, or urea cream). Laser is a joke, just another way to lie to patients for your financial benefit. Much like laser tx for neuropathy (don’t get me started on this BS...).

I also find great success using carbon fiber plating for midfoot OA as well as flexor tenosynovitis. Give it a try. You can get a full length, flat cf plate online for $50. For foot OA I have patients try and fail a plate prior to surgery (I tell patients the plate acts as an “external” fusion).

For neuropathy, I have found success using fat-soluble Thiamine (Benfotiamine) 600mg QD. ALA 600mg and Rheumate are also good, but depends on the person how much it helps. I try these before Gabapentin. I avoid Lyrica.

 

[CutsWithFury]

I agree 100%. When practicing medicine you gotta be practical; as a personal rule, I usually don’t recommend items that I probably wouldnt pay for myself. Patients appreciate it. Don’t be a shyster.

Additional thoughts:

Orthotics - Powersteps are great. Another great option is Spenco Orthotic Arch orthotics ($30 on amazon).

Amen on the urea. I also tell patients to buy 40% online. That, or I give them Kerasal cream coupon (you can get this off their website for free).

Orthotics - for sure send any custom orthotics/bracing to someone who does it for a living and has a workshop to make modifications... orthotist!

Onycho - I tell pts any topical (OTC or Rx) 25% cure, Diflucan 50% cure, Lamisil 75%. If fungus been there for > 5 years or looks terribly dystrophic I tell them to go with softeners (Kerasal lacquer - coupon also online, or urea cream). Laser is a joke, just another way to lie to patients for your financial benefit. Much like laser tx for neuropathy (don’t get me started on this BS...).

I also find great success using carbon fiber plating for midfoot OA as well as flexor tenosynovitis. Give it a try. You can get a full length, flat cf plate online for $50. For foot OA I have patients try and fail a plate prior to surgery (I tell patients the plate acts as an “external” fusion).

For neuropathy, I have found success using fat-soluble Thiamine (Benfotiamine) 600mg QD. ALA 600mg and Rheumate are also good, but depends on the person how much it helps. I try these before Gabapentin. I avoid Lyrica.

Good post.

I like the midfoot OA rec as I get a lot of geriatric females with midfoot arthritis and complaints.

As for trying to treat neuropathy...why? That’s what their PCP is for.

I think medically treating neuropathy as podiatrist is silly. I actually refuse seeing these patients altogether. I am unsure when and where podiatry became the go to referral for the treatment of neuropathy

 

[deleted285117]

My thoughts:

Because other professions are involved or starting to involve themselves in podiatric care (orthopedic injuries, lower ext. derm, wound care, etc.), why give in and allow another aspect of podiatric care to be “hijacked”? We are specialists of all aspects of lower extremity care, which includes neuropathy.

However, I do tell patients that in many instances I “can treat the symptoms but not the source”. For example... LS radiculopathies. I provide oral supplement/shoe recs and refer to PM&R for treatment of the pinched nerve(s).

If someone has neuropathy without an apparent source, I leave the decision for further investigation (labs, EMG, etc.) to the patient, thus neuro referral.

In the very least, if someone is worried about developing neuropathy (ex. decently controlled Diabetic) i’ll tell them to take vit B complex QD.

 

[heybrother]

I'm going to word this carefully if I can - I'll see neuropathy/nerve pain, but my big thing is - this can't be a person who just keeps following up like a plantar fasciitis case that won't resolve. The truth is I don't have much to offer them. Thankfully most patients have already tried gabapentin and lyrica. I offer OTC capsaicin/lidocaine. Most can't tolerate capsaicin (there may even be a fancy new prescription high strength capsaicin). I made a student do a literature review on these forever ago and I'm pretty sure my clinical results have been less favorable than whatever they reported.

I had a nice, but unfortunate patient recently - diabetic, apparently terrible neuropathy, polypharm, tried every medication, etc. She had a whole bunch of other random things I've seen here for that resolve - each time she wants to bring it back to her nerve pain and I'm clear with her - we went through everything about your history and I don't have anything more to offer you.

That said - we're in a hocus pocus thread.
Is there any sort of nerve pain cream ie. a compounded (ha) formulation out there that isn't a scam / $10,000 pharmacy rip-off / I-"own"-thepharmacy-overprescribe-get-money-from-the-pharmacy--->go to jail eventually situation.

 

[heybrother]

Also, I think I saw there's a 2 year podiatry nerve release fellowship. Wrong thread though!?!?

 

[deleted285117]

There’s some literature on topical CBD but not much. I tell pts if they want to try it, go for it.. just don’t buy the Circle K gas station brand ha!

 

[CutsWithFury]

My thoughts:

Because other professions are involved or starting to involve themselves in podiatric care (orthopedic injuries, lower ext. derm, wound care, etc.), why give in and allow another aspect of podiatric care to be “hijacked”? We are specialists of all aspects of lower extremity care, which includes neuropathy.

However, I do tell patients that in many instances I “can treat the symptoms but not the source”. For example... LS radiculopathies. I provide oral supplement/shoe recs and refer to PM&R for treatment of the pinched nerve(s).

If someone has neuropathy without an apparent source, I leave the decision for further investigation (labs, EMG, etc.) to the patient, thus neuro referral.

In the very least, if someone is worried about developing neuropathy (ex. decently controlled Diabetic) i’ll tell them to take vit B complex QD.

Wound care nurses and internists at the wound care center might try to manage the foot and ankle ulcers but in my direct experience they really suck at it. They don’t debride. They don’t do percutaneous tenotomies. They don’t do anything. Then when it goes south they just punt back to the ED and that’s when I fix it.

We have one general surgeon who does foot and ankle wounds but when they go south he magically disappears when the patients hits the ED.

Trust me there is plenty left for podiatry

 

[air bud]

There are some things I tell patients they are wasting their money. For things like CBD and maybe other stuff like blue emu oil, I tell them if they can afford it and they think it works then go ahead and use it. Placebo.effect is real.


Also I have never prescribed a topical antifungal. Waste of money. Againy patient population largely doesn't care what their toenails look like, hiking boots, work boots or snowboots all year round.

Also, I have been using terbinafine for 3-4 weeks a lot more for tinea pedis. OTC and other weak stuff doesn't work. Same dosage 250mg and fixes it right up.

 

[heybrother]

During 4th year I saw a podiatrist do the following:

Bread and butter plantar fasciitis case. You need an injection and some support.

-Blocks his PT nerve.
-Waits.
-Gives a plantar fascial injection.
-Cuts a felt pad -"Longitudinal metatarsal arch pad"
-Glues it to the guys foot and then throws some more tape. Leave this on for several days!

Do you think he bills like 3 different things for that?

Yes. Its nauseating, ridiculous, unnecessary, stupid, etc. There's got to be a reason why.

 

[msuDPM]

Also, I have been using terbinafine for 3-4 weeks a lot more for tinea pedis. OTC and other weak stuff doesn't work. Same dosage 250mg and fixes it right up.

Do this all the time in patients that have tried other stuff or more severe case. 21 days Lamisil. I dont check labs doing that. When dosing for nail fungus I do daily for 12 weeks, tell them they won't see the final result for 6 to 9 months. As long as they have a CMP in the past 6 months I dont order labs before. I do recheck LFTs at 4 weeks and have taken 2 or 3 off of it early. As long as labs look fine i typically don't see these people back unless they want a nail avulsion.

I'm hospital employed so I don't dispense a thing. I give away gel toe sleeves, heel wedges, etc. Local pharmacy carries powersteps for like 23 bucks. I do see ~30% medicaid, which in my area pays for customs so for many of them ill send for customs that I order to be fabricated basically like powersteps. Our PT dept does casting and dispensing, i write the script.

I do write for some of the compounding stuff from a local pharmacy, not because I believe in it, but because I see a ridiculous amount of people on 800mg gabapentin TID and complain of burning still and ask "isn't there something I can rub on it"...I'd say about 40% of people I give it to say it helps.

In reality I try to not see the nail fungus, neuropathy, callus in nondiabetics...not because I think I'm too good for it, but rather I'm busy enough and I think these are things that their pcp can help with. The people that come to the doctor for these issues also tend to be the people that no show their follow up and call with an issue or refill request out of the blue 6 months later.

 

[DYK343]

Also, I have been using terbinafine for 3-4 weeks a lot more for tinea pedis. OTC and other weak stuff doesn't work. Same dosage 250mg and fixes it right up.

Gotta stop the hyperhydrosis. If you dont then nothing really works - even 4 weeks oral terbinafine. It will still come back. Later on sure. But it will return.

Certain Dri topically every 2-3 days (or knock off equivalent) and whatever OTC topical antifungal x 10-14 days works like a charm.

 

[DYK343]

Also, I think I saw there's a 2 year podiatry nerve release fellowship. Wrong thread though!?!?

I would sincerely LOVE a nerve fellow to open up shop around me. I would send 100% of my nerve pain patients out. I have given up on all nerve surgery. I tell them I am not good at it, my results suck, and go to someone better than me.


...why anyone would want to sign up for a life of treating nerve pain patients is beyond me. The problem is real. But 100% rolling the dice going in there with a blade. Nothing worse than an unhappy nerve patient postop.

 

[air bud]

I would sincerely LOVE a nerve fellow to open up shop around me. I would send 100% of my nerve pain patients out. I have given up on all nerve surgery. I tell them I am not good at it, my results suck, and go to someone better than me.


...why anyone would want to sign up for a life of treating nerve pain patients is beyond me. The problem is real. But 100% rolling the dice going in there with a blade. Nothing worse than an unhappy nerve patient postop.

Yeah I am done with tarsal tunnel. Send to nerve specialist 4 hours away

 

[DYK343]

Yeah I am done with tarsal tunnel. Send to nerve specialist 4 hours away

I dont even want to do mortons neuromas anymore. How many times have you seen a patient with incisional scars over every dorsal intermetatarsal space as well as plantar incisions looking for a 16th opinion? The pain is real. I dont deny that. But... No thanks.

 

[heybrother]

I saw very little "new" tarsal tunnel in residency - though I followed several very, very unhappy people who'd been operated on elsewhere. If they pronated at all we tried to resolve the mechanical issue which sometimes resolved the nerve pain. We also attempted to treat all forefoot pain as mechanical to the best of our ability - I think ultimately most were capsulitis with localized swelling causing nerve irritation.

So funny story. I've had 2 brand new patients within the last month with something vaguely resembling tarsal tunnel AND they start describing laterally shooting pain that starts medially and traverses across the foot. I think I'm supposed to hear 1st branch of lateral plantar nerve.

Options
(a) continue straightforward conservative therapy
(b) runaway
(c) like a bullet, divide and tear fascial layers of the foot apart from one side to the other. Apologize for 90 days.
(d) find out where airbud lives and then refer to his guy

 

[king22]

I have been using Formula 7 for the past several months and have been pleasantly surprised by it. I've tried it on a few of my Medicare patients (so you know the only topical that's available to them Rx is ciclopirox) with decently dystrophic nails and I'm actually seeing improvement. Formula 3 never seemed to do anything though.


As for night splints- I find them to be quite beneficial to patient's who have most of their pain just in the beginning of the morning when they get up. I'd say 3/4 tolerate it well. Anyone who doesn't tolerate it I tell them to bring it back the next visit and we will refund them.

 

[shadesofgrey]

A few observations from my experience as a new practitioner in private practice.

Nerve conditions are the worst. Have done a few Tarsal tunnels, will try very hard to never do them again. As for neuropathy, I would prefer not to treat them but I keep getting referrals to treat it so I feel compelled to at least initiate the work up. As a result, I am fairly comfortable using Gabapentin, so I will often times start that. Rarely use Lyrica. I also use a compounding pharmacy, but am quite honest that it often won't work and advise pts to get the price prior to agreeing. I really hate when the PCP tries all this stuff and then still sends the referral. What the hell am I gonna do with them? You already treated them.

Antifungals: I normally use terbinafine for 3 months with one blood test for patients that want the best shot at getting rid of fungus. As for topicals, our office had been using formula 3 (complete trash) but recently switched to Tolcylen (partly trash?). As an associate with no financial interest, I have viewed the in-office topicals as just a way to milk more money from the patients and largely avoid them. However, my boss uses Tolcylen quite extensively, and I have seen some improvement with Tolcylen. Haven't seen a complete cure but was surprised that the nail was definitely improving. Honestly, I would probably use it more if our office didn't charge so much for it. It's hard to advise a patient spend $60 on a product that might help... some... a little... it's better than Vicks... I think... but then I'm not much for sales...

Bako: I'll send a nail biopsy out if I can't tell fungal vs micro-trauma in a patient that is really interested in knowing. Maybe once a month? I did make the mistake of brazenly selecting the PCR test once and the patient had one of the crappy, religious, charity, health insurance plans. They called very angry that the bill was >$500. Our office called and apparently the culture fungus option is around $30. So I normally do that one.

Night splints and custom orthotics: I will do night splints and custom orthotics only if insurance covers it, otherwise I send them to amazon for the splint and OTC powersteps. (If your a practice owner, take note and offer your associate a cut of the DME and maybe they will push more inventory)

Swyft: I've never used it, but it seems like it works similar to a panacos procedure. We typically use canthacure, excision, laser, or panacos at our office. Patients don't typically want to commit to the more aggressive treatments like excision, laser or panacos. Which means I just keep putting acid on the warts and in a bad case it can take a long time. I hate warts and if the Swyft worked I would use it just to be rid of them sooner. Bring them in, zap them 2-3 times, and see ya later, sounds dreamy...

Any poor bastards still work in an office that grinds nails or uses soak tubs? Whew at least I dodged that bullet.

I would like to chat more, but there's an old woman waiting to heckle me for not cutting the corner of her nails back far enough the last time. God, isn't podiatry the greatest? it makes me sad to think that in 30 years I will have to retire.

 

[air bud]

A few observations from my experience as a new practitioner in private practice.

Nerve conditions are the worst. Have done a few Tarsal tunnels, will try very hard to never do them again. As for neuropathy, I would prefer not to treat them but I keep getting referrals to treat it so I feel compelled to at least initiate the work up. As a result, I am fairly comfortable using Gabapentin, so I will often times start that. Rarely use Lyrica. I also use a compounding pharmacy, but am quite honest that it often won't work and advise pts to get the price prior to agreeing. I really hate when the PCP tries all this stuff and then still sends the referral. What the hell am I gonna do with them? You already treated them.

Antifungals: I normally use terbinafine for 3 months with one blood test for patients that want the best shot at getting rid of fungus. As for topicals, our office had been using formula 3 (complete trash) but recently switched to Tolcylen (partly trash?). As an associate with no financial interest, I have viewed the in-office topicals as just a way to milk more money from the patients and largely avoid them. However, my boss uses Tolcylen quite extensively, and I have seen some improvement with Tolcylen. Haven't seen a complete cure but was surprised that the nail was definitely improving. Honestly, I would probably use it more if our office didn't charge so much for it. It's hard to advise a patient spend $60 on a product that might help... some... a little... it's better than Vicks... I think... but then I'm not much for sales...

Bako: I'll send a nail biopsy out if I can't tell fungal vs micro-trauma in a patient that is really interested in knowing. Maybe once a month? I did make the mistake of brazenly selecting the PCR test once and the patient had one of the crappy, religious, charity, health insurance plans. They called very angry that the bill was >$500. Our office called and apparently the culture fungus option is around $30. So I normally do that one.

Night splints and custom orthotics: I will do night splints and custom orthotics only if insurance covers it, otherwise I send them to amazon for the splint and OTC powersteps. (If your a practice owner, take note and offer your associate a cut of the DME and maybe they will push more inventory)

Swyft: I've never used it, but it seems like it works similar to a panacos procedure. We typically use canthacure, excision, laser, or panacos at our office. Patients don't typically want to commit to the more aggressive treatments like excision, laser or panacos. Which means I just keep putting acid on the warts and in a bad case it can take a long time. I hate warts and if the Swyft worked I would use it just to be rid of them sooner. Bring them in, zap them 2-3 times, and see ya later, sounds dreamy...

Any poor bastards still work in an office that grinds nails or uses soak tubs? Whew at least I dodged that bullet.

I would like to chat more, but there's an old woman waiting to heckle me for not cutting the corner of her nails back far enough the last time. God, isn't podiatry the greatest? it makes me sad to think that in 30 years I will have to retire.

Why isn't anyone on here talking about all the TARS they are doing or the high level athletes they are treating? SDN probably is just a poor representation of the profession....ssshhhhh don't let the prepods find out

 

[shadesofgrey]

Actually I brought up a "hocus pocus" treatment in my post without realizing it!! Anybody else do Panacos graft procedure? I never used it in residency, but the practice I joined does a fair amount of them. I'd say I get a referral specifically for the procedure at least monthly from a dermatologist. I've probably done 15 of them now and only had one fail (yes, yes very anecdotal).

Dr. Markinson just trashed the procedure over the weekend in everyone's favorite email, "PM News". I confess, I haven't read much literature on the procedure. I guess I'll have to review it, but honestly it's one of my favorite wart treatments.

 

[DYK343]

Actually I brought up a "hocus pocus" treatment in my post without realizing it!! Anybody else do Panacos graft procedure? I never used it in residency, but the practice I joined does a fair amount of them. I'd say I get a referral specifically for the procedure at least monthly from a dermatologist. I've probably done 15 of them now and only had one fail (yes, yes very anecdotal).

Dr. Markinson just trashed the procedure over the weekend in everyone's favorite email, "PM News". I confess, I haven't read much literature on the procedure. I guess I'll have to review it, but honestly it's one of my favorite wart treatments.

In my experience it can work. I've tried it when everything else failed and got total resolution of all lesions within 30 days. I tried it when everything else failed on a different patient and the warts persisted.

 

[CutsWithFury]

Actually I brought up a "hocus pocus" treatment in my post without realizing it!! Anybody else do Panacos graft procedure? I never used it in residency, but the practice I joined does a fair amount of them. I'd say I get a referral specifically for the procedure at least monthly from a dermatologist. I've probably done 15 of them now and only had one fail (yes, yes very anecdotal).

Dr. Markinson just trashed the procedure over the weekend in everyone's favorite email, "PM News". I confess, I haven't read much literature on the procedure. I guess I'll have to review it, but honestly it's one of my favorite wart treatments.

Just excise and do a rotational skin plasty.

 

[shadesofgrey]

Just excise and do a rotational skin plasty.

I should have been more specific. I only do this procedure if there are multiple warts or large patches that are at different spots on the foot and not easily amenable to excision.

 

[ExperiencedDPM]

Young healthy why test labs? Waste of money they are fine. Also ALT can be 2x before need to worry. Older I may do labs once but again if no history of disease no reason to test twice. If serious fungus I won't give, tell them to live with it. Mild to moderate I say may work, 70 percent effective. The most important thing is to educate them on how it works. Take a pic today, in one month, in two months etc...don't think about seeing results for a leat three. Don't come to me until 6 months to complain it didn't work. No laser. Fortunately where I live nobody paints there nails or wears sandals to look good.

Orthotics. 99 percent do great with powersteps. True deformity gets custom from orthotist who knows what they are doing.

Manual muscle testing - scam

Balance braces - scam

Genetic testing - scam

Antibiotic foot baths - scam

In office shoes....there is literally not a place within 3 hours of me to buy shoes not at a Walmart. I am actually trying to figure out how to carry vionic/Birkenstock or something along those lines.

Hokas - scam. (Not really...) Asics/powersteps fixes everyone's problems. Get the style guide from a few years ago not the new one, does a better job of showing them categories. Go on to Amazon and get last year's model for half the price. Flat - gt2000 literally every person lives them. High? I think it's the cumulus but may be wrong.

Anything that is not stretching, not going barefoot (Burks/vionic sandals for the house) is a scam. Steroid injections obviously too. Night splints? Everyone hates them and doesn't use them and gets crappy sleep even if they work. Tell patient but make buy on their own.

Pain on met bases? Surgical shoe 50k units vd3 once a week for 6 weeks no labs see you in 3 weeks.

Big heal callus? 15 dollar 40 percent urea cream on Amazon, not that Blain labs **** this isn't 2012.

Nutraceuticals - scam

Anything you sell in your office besides some basic OTC orthotics, crest pads, toe spacers etc. - scam

Pain, no recent trauma to decrease healing process? Boot and medrol dosepack. Steroids fix everything. Wear the boot while sleeping when on steroids.

These are real people. With real bills to pay. I live in a tiny ( you have no idea...) Town. These are my neighbors, I see them at the grocery store, at the gym, at the baseball game. Much of the problem is that in big cities you never see these people outside of the office. Just a blank checkbook to you. What can you get them/insurance to pay.

There you go new grads/3rd years you know how to deal with 75 percent of patients. Thanks for coming to my TED talk.

Be cautious with those Medrol dose packs. One of my partners wrote Rxs for it as if it was candy.

Sobering Data on Risks of Short-Term Oral Corticosteroids

Short steroid bursts linked to serious adverse events within a month

www.medpagetoday.com

 

[DYK343]

I've had zero percent long term benefits of medrol dose packs for treatment of pain/inflammation.

 

[air bud]

I've had zero percent long term benefits of medrol dose packs for treatment of pain/inflammation.

What? That's crazy. PT tendonitis? Peroneal tendonitis? Achilles tendonitis without spur? Literally everyone gets better with a tall boot and medrol dosepack. Sleep in the boot while on steroid. Last day switch to Meloxicam 15mg a day. Follow up in 3 to 4 weeks. 100 percent.

 

[G0dFather]

I've had zero percent long term benefits of medrol dose packs for treatment of pain/inflammation.

classic

 

[deleted285117]

What is everyone’s thoughts on ESWT?

Also.... Prolotherapy. A residency director I shadowed as a student did it. Evidence pretty lacking.

 

[CutsWithFury]

What is everyone’s thoughts on ESWT?

Also.... Prolotherapy. A residency director I shadowed as a student did it. Evidence pretty lacking.

I have access to a shockwave device in my clinic. I think it def helps. At best it minimizes painful symptoms to a point where the patient can function again without surgery. I've never had 100% improvement. Biggest problem I have utilizing it is that patient's can't afford the out of pocket fee which we already knocked down significantly to only $100 per session. I see a lot of medicaid so that is one of the main reasons.

I would do it for free if the hospital wasn't on my butt to get some money out of the machine.

 

[josebiwasabi]

We have a Shockwave machine in our office, we have one major commercial insurance carrier that covers it with 3 months of failed other treatments. Everyone else is self pay. We add a low dye strapping for free at the end of the session.

We do a series of 5 treatments, 1 session per week. They can expect continued improvement for up to 3 months after the last treatment.

I have found about a 80% success rate in getting pain down to a 1 or 2 out of 10, and these are the patients who have failed all of the traditional treatments.

I see them 3 months later for follow up and if they are still having debilitating pain we talk about surgical options. My preferred initial surgical procedure is the Topaz since it leaves the fascia intact. If that doesn't work, then they get a fasciotomy.

Anyone do anything significantly different?

 

[heybrother]

I'm trying to read up on ESWT devices/find out what they cost, but apparently there's also ESWT for erectile dysfunction and its getting top billing.

STORZ MEDICAL – Shock wave devices and lithotripters for lithotripsy, urology, orthopedics, cardiology, neurology, aesthetics and veterinary medicine

Would someone else please click on the above link and look through the page. I need to know I'm not the only person who has seen these.

 

[Utvolsdpm]

Speaking of topaz- does Tenex count as hocus pocus? I have to admit I haven’t read up on it although I did a few in residency.

 

[air bud]

Speaking of topaz- does Tenex count as hocus pocus? I have to admit I haven’t read up on it although I did a few in residency.

Yes