Podiatry hocus pocus, lotions and potions, lies and shenanigans

[air bud]

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Ok who actually does low dye taping? Never saw it once in residency. Saw a few times 4th year. Just start doing eccentric stretching, I gave you a steroid shot today. Get some powersteps and Asics gt2000(flat)nimbus or cumulus (high) and start getting better. Also some Meloxicam

 

[CutsWithFury]

I don’t understand the purpose of Topaz. The plantar fascia hurts because it’s either turned into plantar fasciosis or the patient is just too lazy to stretch and it is perpetually tight. Just do plantar fasciotomy. And if they are really tight in the gastrocnemius then do a strayer.

 

[deleted285117]

I consider PRP hocus pocus.

 

[DYK343]

I did 3-5 topaz cases in residency. Super easy. I have not done it since. Anyone see results with it? How does one even bill for it?

 

[DYK343]

I don’t understand the purpose of Topaz. The plantar fascia hurts because it’s either turned into plantar fasciosis or the patient is just too lazy to stretch and it is perpetually tight. Just do plantar fasciotomy. And if they are really tight in the gastrocnemius then do a strayer.

What about hammertoe development and lateral column pain S/P plantar fasciotomy? Last time I did a literature review, admitingly its been awhile, people developed these symptoms later in life even if "only the medial band" was cut.

I have not had to do any fasciotomies since residency. I have a 99% cure rate without the need for it. Stretching, aggressive icing, massaging, wearing supportive shoes with first step in the morning, massaging before getting out of bed in the morning, and a cortisone injection if they want. NSAIDs if appropriate. I spend a lot of time explaining the pathology behind it and if they understand it they actually do the conservative treatments and get better - at least in my experience.

The 1-2 that I didnt get better ended up going somewhere else. I offered topaz on one of them but they declined.

 

[CutsWithFury]

What about hammertoe development and lateral column pain S/P plantar fasciotomy? Last time I did a literature review, admitingly its been awhile, people developed these symptoms later in life even if "only the medial band" was cut.

I have not had to do any fasciotomies since residency. I have a 99% cure rate without the need for it. Stretching, aggressive icing, massaging, wearing supportive shoes with first step in the morning, massaging before getting out of bed in the morning, and a cortisone injection if they want. NSAIDs if appropriate. I spend a lot of time explaining the pathology behind it and if they understand it they actually do the conservative treatments and get better - at least in my experience.

The 1-2 that I didnt get better ended up going somewhere else. I offered topaz on one of them but they declined.

Too young in my career to see these develop in my post op patients down the road. Have not had any complaints of lateral column pain or progressive hammertoe deformity

 

[ExperiencedDPM]

I did 3-5 topaz cases in residency. Super easy. I have not done it since. Anyone see results with it? How does one even bill for it?

There is no legitimate code for it despite what the reps will tell you. They recommend billing a tenolysis, synovectomy, blah, blah, blah.

 

[air bud]

What about hammertoe development and lateral column pain S/P plantar fasciotomy? Last time I did a literature review, admitingly its been awhile, people developed these symptoms later in life even if "only the medial band" was cut.

I have not had to do any fasciotomies since residency. I have a 99% cure rate without the need for it. Stretching, aggressive icing, massaging, wearing supportive shoes with first step in the morning, massaging before getting out of bed in the morning, and a cortisone injection if they want. NSAIDs if appropriate. I spend a lot of time explaining the pathology behind it and if they understand it they actually do the conservative treatments and get better - at least in my experience.

The 1-2 that I didnt get better ended up going somewhere else. I offered topaz on one of them but they declined.

I totally agree. I hate plantar fascia surgery.

 

[DYK343]

Also, are strayers going away? I guess thats not fair question as most people probably still do them given their popularity. I exclusively do baumann now and have had great success. 5 minute procedure. No loss of strength or definition. No ankle swelling. No sural nerve problems. Love them.

 

[ExperiencedDPM]

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

There is no physiatrist, neurologist, etc., who treats balance issues who has ever heard of, let alone prescribe a “balance brace”. The thief who started it uses scare tactics for older patients and shows them pics of an elderly person on the floor.

It is also pure insurance fraud. NO insurance pays for “balance braces”. So they bring patients in the door under the guise of a balance brace/fall prevention brace, but bill it to the insurance under some fabricated musculoskeletal diagnosis.

If you prescribe these you are a thief who doesn’t understand biomechanics.

 

[msuDPM]

I totally agree. I hate plantar fascia surgery.

I try to avoid it as much as possible, but think it's more of a patient selection problem than procedural problem. Those that go on to plantar fasciotomy seem to just be "that type" of patient. Have done minimally invasive/percutaneous, open instep and epf. Have recently returned to epf, feel like I've had the best overall results with it. Probably have done 10-14 plantar fasciotomies in 4 years, though. Did some Topaz in residency, but we don't have a machine. Have never used a Tenex.

Speaking on Prolotherapy....I have one patient I have done in on probably 4 or 5 times. She is a hairdresser who owns her own shop. Has grade 3 HR. Had a bad reaction to a steroid inj at one point, some other provider previously did Prolotherapy on her and she came to me requesting it. So I researched it a bit and subjectively it seems to help her. Conversely I did it to her once for PF and she said it didn't help at all.

 

[msuDPM]

There is no physiatrist, neurologist, etc., who treats balance issues who has ever heard of, let alone prescribe a “balance brace”. The thief who started it uses scare tactics for older patients and shows them pics of an elderly person on the floor.

It is also pure insurance fraud. NO insurance pays for “balance braces”. So they bring patients in the door under the guise of a balance brace/fall prevention brace, but bill it to the insurance under some fabricated musculoskeletal diagnosis.

If you prescribe these you are a thief who doesn’t understand biomechanics.

How dare you discount the illustrious Dr. Moore and his world renowned gait and balance center in Somerset, KY? LOL.

 

[heybrother]

I've been thinking about my complicated people lately who don't get better. You go full bore conservative. They only marginally improve. When someone has a bunch of issues - autoimmune, neurologic, fibromyalgia, persistent plantar fascial pain, and ...insanity/non-compliance - do you pull the trigger on a gastrocnemius recession or some sort of plantar fascial surgery (...tarsal tunnel)? Or do you say - your pain is complicated and fixing your MSK problem probably isn't actually going to help you.

-30 year old girl. She has some sort of nerve tumor that she refuses to have biopsied and comes to you to make sure the foot was fully worked up. 350 lbs. Equinus. Diffuse pain everywhere. Couldn't point to it in the first few visits. Started off neurologic. Ultimately became focal plantar fascial pain maybe. Won't really do anything you say. Shows up in sandals and says her feet hurt because she was jumping on a trampoline the day before. Persistent foot swelling. Offer MRI. She wants it and then stops following up.

-50 year guy. He shows up telling you he's been going to chiropractors for 2 years with no benefit or effect. Has seen rheumatology. Has some sort of unidentified auto-immune condition. You put him in Hokas/inserts, stretching, and give 2 injections. He says its the best thing in 2 years but he's still only 40% improved. He regularly describes shooting leg pains radiating up and down the leg.

-30ish year old female. Active job. Fibromyalgia. Lots of anti-depressants. Gabapentin. Some effect from plantar fascial injections. Continued foot and radiating nerve pain to the left leg. Some tarsal tunnel type complaints. Asked her to get a second opinion. An ortho threw some steroid in her tarsal tunnel on both feet - 1 worked. He told her she'd never benefit from surgery and should go to pain medicine.

I didn't operate on these people. I mostly think I did the right thing. But I wonder if somehow I'm doing analysis paralysis. I feel like there's someone out there who would have said - la la la - ignore those nerve pains, screw it, I'm cutting. My weird thing - conservative plantar fascial therapy works so well (I think) that its just weird reaching the end of the tunnel. Am enjoying hearing about more of these conservative things.

 

[CutsWithFury]

I've been thinking about my complicated people lately who don't get better. You go full bore conservative. They only marginally improve. When someone has a bunch of issues - autoimmune, neurologic, fibromyalgia, persistent plantar fascial pain, and ...insanity/non-compliance - do you pull the trigger on a gastrocnemius recession or some sort of plantar fascial surgery (...tarsal tunnel)? Or do you say - your pain is complicated and fixing your MSK problem probably isn't actually going to help you.

-30 year old girl. She has some sort of nerve tumor that she refuses to have biopsied and comes to you to make sure the foot was fully worked up. 350 lbs. Equinus. Diffuse pain everywhere. Couldn't point to it in the first few visits. Started off neurologic. Ultimately became focal plantar fascial pain maybe. Won't really do anything you say. Shows up in sandals and says her feet hurt because she was jumping on a trampoline the day before. Persistent foot swelling. Offer MRI. She wants it and then stops following up.

-50 year guy. He shows up telling you he's been going to chiropractors for 2 years with no benefit or effect. Has seen rheumatology. Has some sort of unidentified auto-immune condition. You put him in Hokas/inserts, stretching, and give 2 injections. He says its the best thing in 2 years but he's still only 40% improved. He regularly describes shooting leg pains radiating up and down the leg.

-30ish year old female. Active job. Fibromyalgia. Lots of anti-depressants. Gabapentin. Some effect from plantar fascial injections. Continued foot and radiating nerve pain to the left leg. Some tarsal tunnel type complaints. Asked her to get a second opinion. An ortho threw some steroid in her tarsal tunnel on both feet - 1 worked. He told her she'd never benefit from surgery and should go to pain medicine.

I didn't operate on these people. I mostly think I did the right thing. But I wonder if somehow I'm doing analysis paralysis. I feel like there's someone out there who would have said - la la la - ignore those nerve pains, screw it, I'm cutting. My weird thing - conservative plantar fascial therapy works so well (I think) that its just weird reaching the end of the tunnel. Am enjoying hearing about more of these conservative things.

Good choice not to cut. I’m only three years into practice but my days of doing tarsal tunnel surgery are over. It doesn’t work. And I don’t care enough to attend a microsurgical nerve course that some DPMs are obsessed with.

Most nerve pain is medically managed by the patients PCP or a neurologist in my region.

If I saw any of the above patients who endorse these shooting pain symptoms I’ll just order an EMG and not think twice. The physiatrist in my group loves me because I throw him EMGs left and right. A lot of the time these symptoms are not made up and there is an identified nerve pathology either at the level of the lower back or an isolated nerve injury at the lower extremity. Once I get confirmation of that I basically tell the patient they aren’t a good candidate and to see neurology or a possible pain specialist. Then I PRN their ass.

 

[CutsWithFury]

Not a hocus pocus topic but I’ll I just want to say that I don’t think PCPs really care to treat a patients gout symptoms.

I’ll get patients with a history of gout who are referred to me for chronic foot swelling pain or great toe pain. They aren’t on their gout meds anymore for whatever reason because the PCP took them off of it. We get a Uric acid level and it’s through the roof.

This happens to me like once a month at least. I don’t understand why gout meds are stopped.

Maybe PCPs think gout is hocus pocus.

 

[air bud]

Totally agree about nerve stuff. No more tarsal tunnel for me. Neuroma fine. Nothing else. Saw a lady today that had 90 percent improvement for 6 months after neuroma excision. Now bothering her. Injection didn't work. I am not going in trying to fix that. Today much more tender, double crush with tinel on bilateral DP and tarsal tunnel. I gave her the option of EMGs and send to nerve specialist in big city 6 hours away. Or try and treat symptoms. Placed on gabapentin 300mg TID. Unlike @CutsWithFury I treat neuropathy all the time. Of course nearest neurologist is 90 mins away. And he is a crook and orders a million labs and EMGs on every patient. Never prescribed Lyrica before. Mixed success with duloxetine after fails gabapentin. But gabapentin is awesome. No history of seizure and not on any neuro meds like carbamezipine or halidol or something like that? They are getting gabapentin. I see lots of patients for diabetic nail care that are on something like 100mg TID per PCP. I just increase it and they are like holy crap that's all we had to do? Anything less than 300 is crap (unless post op I will put on 100mg TID of think will have some nerve issues ( exame peroneal surgery).

Anyways nerves suck.

 

[DYK343]

There is no legitimate code for it despite what the reps will tell you. They recommend billing a tenolysis, synovectomy, blah, blah, blah.

If you do do this procedure bill as an unlisted CPT code? I haven't done it since residency but I've considered it as I mentioned above. The provider who I did them with in residency said he got really good results. I favor trying topaz (or shockwave) over a release of the plantar fascia as I stated above.

 

[dtrack22]

If you do do this procedure bill as an unlisted CPT code?

you should. But you are unlikely to get paid (in either a direct collection or wRVU payment model), which is why more people don’t.

 

[ExperiencedDPM]

If you do do this procedure bill as an unlisted CPT code? I haven't done it since residency but I've considered it as I mentioned above. The provider who I did them with in residency said he got really good results. I favor trying topaz (or shockwave) over a release of the plantar fascia as I stated above.

Any procedure that does not have a specific code, should be billed as an unlisted procedure. It is incorrect to bill the “closest thing”.

Many will argue that insurers never pay for unlisted codes and that is not true. To get paid for an unlisted code, you must specifically explain in your op report why you are billing an unlisted code and which part of your procedure is associated with the unlisted code.

 

[ExperiencedDPM]

Good choice not to cut. I’m only three years into practice but my days of doing tarsal tunnel surgery are over. It doesn’t work. And I don’t care enough to attend a microsurgical nerve course that some DPMs are obsessed with.

Most nerve pain is medically managed by the patients PCP or a neurologist in my region.

If I saw any of the above patients who endorse these shooting pain symptoms I’ll just order an EMG and not think twice. The physiatrist in my group loves me because I throw him EMGs left and right. A lot of the time these symptoms are not made up and there is an identified nerve pathology either at the level of the lower back or an isolated nerve injury at the lower extremity. Once I get confirmation of that I basically tell the patient they aren’t a good candidate and to see neurology or a possible pain specialist. Then I PRN their ass.

In my opinion, tarsal tunnel surgical patients get one of two results.

100% better or 100% worse. Rarely if ever does a patient get moderately better. It’s an all or none phenomena.

I can honestly say that I was fortunate and always had great results. I chose my patients wisely. Despite having great results, I abandoned the procedure since I KNEW it was a matter of time before I had that nightmare TTS surgical patient, since I have seen so many failures and most cases were done by skilled surgeons.

I quit while I was ahead of the curve.

 

[air bud]

In my opinion, tarsal tunnel surgical patients get one of two results.

100% better or 100% worse. Rarely if ever does a patient get moderately better. It’s an all or none phenomena.

I can honestly say that I was fortunate and always had great results. I chose my patients wisely. Despite having great results, I abandoned the procedure since I KNEW it was a matter of time before I had that nightmare TTS surgical patient, since I have seen so many failures and most cases were done by skilled surgeons.

I quit while I was ahead of the curve.

This

 

[heybrother]

So here's a fun one. A 40ish year old guy drives to my office with his wife. The first time I saw him his discomfort was diffuse everywhere around the ankle, tarsal tunnels, rearfoot etc. No trauma. Guarding. Tight. I'm always a bit skeptical when someone does the everything hurts game. Like my perfect world is - by the time you come back for second visit we can reduce your pain down to something more specific than everywhere. Tried the basics, ROM, steroids, stretching.

At next visit he's still tight, no improvement - we focus in on the tarsal tunnel. He then says - the real issue is not the tarsal tunnel pain - whenever my tarsal tunnel triggers pain - I vomit or nearly vomit. How often? Everyday. On the way here etc.

So I refer him to neurology for NC/EMG - whatever and specifically write on the consult the patient states he vomits when it triggers. And of course, they didn't discuss this at all during their hour appointment. Neurology states confirmation of tarsal tunnel.

Went ahead and ordered MRI (space occupying lesions, something wild or different, whatever) and physical therapy. Wonder where this will go. The whole vomiting after pain thing makes me think it would be wonderful if a neurology or pain specialist became a player in this game.

 

[Sartorius P.O.D.]

I am unsure when and where podiatry became the go to referral for the treatment of neuropathy

LOL. This whole profession exists to treat the stupid little crap nobody else wants to deal with.

 

[G0dFather]

Also, are strayers going away? I guess thats not fair question as most people probably still do them given their popularity. I exclusively do baumann now and have had great success. 5 minute procedure. No loss of strength or definition. No ankle swelling. No sural nerve problems. Love them.

Baumann is great ... using an anal retractor makes it even easier .. first time i asked for it i caused serious confusion in the OR !

 

[air bud]

Baumann is great ... using an anal retractor makes it even easier .. first time i asked for it i caused serious confusion in the OR !

Wait anal retractor? I use the pediatric vaginal speculum...

 

[Pronation]

Uh, I feel so vanilla doing a plain Jane Strayer gastroc recession with a knife and pickups...

 

[ExperiencedDPM]

Wait anal retractor? I use the pediatric vaginal speculum...

I’m going to have both of you arrested.

 

[heybrother]

Anyone use the Arthrex endoscopic strayer system? How much does that cost?

I've seen some complications -an enormous posterior leg divet that was very visible after the fact. A very unhappy bagged sural - they had been sent for 6 months of physical therapy.

 

[DYK343]

Anyone use the Arthrex endoscopic strayer system? How much does that cost?

I've seen some complications -an enormous posterior leg divet that was very visible after the fact. A very unhappy bagged sural - they had been sent for 6 months of physical therapy.

I saw a TON of complications from this in residency. Another provider in town did them and constantly had bad results that ended up in our clinic. At least 3-4 I saw and I was only in clinic 1.5 days a week.

 

[G0dFather]

Wait anal retractor? I use the pediatric vaginal speculum...

Check it out its very easy, dr deehr has a video of his doing one using the tool

 

[CutsWithFury]

I saw a TON of complications from this in residency. Another provider in town did them and constantly had bad results that ended up in our clinic. At least 3-4 I saw and I was only in clinic 1.5 days a week.

I prefer to open my strayers. I mainly do them prone with my plantar fasciotomy. Easy dissection and takes minimal time.

If I do it from the supine position I’ll just externally rotate the leg as much as I can and most of the time I can get the same visualization.

 

[DYK343]

Check it out its very easy, dr deehr has a video of his doing one using the tool

I think he was just joking... anal/vaginal distractors are what is used for the procedure. I personally lean towards vaginal myself but to each their own.

Now pediatric..........

Anyways if you guys are not doing Baumann gastroc lengthening you should look into it. Its 10x better than strayer.

 

[DYK343]

I prefer to open my strayers. I mainly do them prone with my plantar fasciotomy. Easy dissection and takes minimal time.

If I do it from the supine position I’ll just externally rotate the leg as much as I can and most of the time I can get the same visualization.

Yeah I would avoid the arthrex system. It saw way too many complications from it but its possible the guy was just a hack. Scared me away from doing it.

 

[air bud]

I prefer to open my strayers. I mainly do them prone with my plantar fasciotomy. Easy dissection and takes minimal time.

If I do it from the supine position I’ll just externally rotate the leg as much as I can and most of the time I can get the same visualization.

Just get someone to hold the leg up,.easy to do upside down. In residency the attending did the gastroc and we did the flatfoot recon. Just because they didn't want to uhold the leg. tbh though looking back I don't know why we did that and didn't just do a baumnann.

 

[ExperiencedDPM]

Anyone use the Arthrex endoscopic strayer system? How much does that cost?

I've seen some complications -an enormous posterior leg divet that was very visible after the fact. A very unhappy bagged sural - they had been sent for 6 months of physical therapy.

Tweaking the sural nerve is not uncommon with endoscopic release.

 

[Scrantonicity]

9 times outta 10 I don't have to do plantar fascia release, but it seems like when I do the plantar fascia is SUPER thick. Like, takes 2 or 3 passes with the blade to get through it thick. I think when it becomes that thick and scarred, it's almost impossible to get it better with conservative therapy. I've never seen hammertoes because of it, but I have had a small percentage of patients complain of lateral foot pain--but that lateral foot pain/instability hurts less than the plantar fasciitis did.