30 | Oct | 2012

Podiatrists and Foot & Ankle Orthopedic Surgeons

This blog addresses a question by one of AO’s readers: Based on surgical outcomes, when should a person see a podiatrist, and when should that person see a foot and ankle orthopedic surgeon?

This question is difficult to answer. Of course I would be biased towards an MD, orthopedic surgeon, fellowship trained in the care of the foot and ankle over a podiatrist.

The real answer is there are good and bad in both disciplines…but how do you find out who is the right person for you or your family member?

Here are some ways to vet the right doc, of any kind, especially a surgeon.

1. The best referrals are from patients who have been there. Your doctor might not be the best source for a referral. If I am asked by my patient about another doc—a heart surgeon let’s say—I will usually not give a referral because I don’t really know these people and I certainly don’t know how good a doc/surgeon they might be.

At the end of the day I really don’t know most of these other docs, but I hear stories (see #2). Sometimes no referral is the best route.

2. Find someone this doc might work with in the OR, like a nurse, anesthetists, etc. These people are with the surgeon in the heat of battle and that is when a surgeon’s true colors show! That is exactly how I found my urologist 13 years ago, but I have means the common person does not. So, do your best to ask around.

3. Be forward and ask the doc you are in front of how many of these procedures they have done. If that upsets them…RUN. What are the expected downsides and risks of a particular procedure? What is the recovery going to be?

4. Talk to patients in the waiting room. But beware, you might be thrown off by the complainer. You might have to throw out the highs and the lows. This approach can be much like reviews of products online and has to be filtered a bit…A constructive criticism looks very different from whining and complaining.

5. Don’t choose your doc/surgeon based on their wonderful personality. Your prospective doc could be a jerk, curmudgeon, or just not warm and fuzzy, but they could still be a great surgeon, who gets great results. See #1 and #2. Face it, you’re not going there to date them, you are going for a service.

6. When all else fails, get another opinion. If you are really looking at surgery, get another opinion and then choose. But a word of warning: too many and differing opinions can cause confusion. If you do this do not tell the next guy what the first guy said—don’t even tell them you saw someone else. Then you will get unbiased opinion. Notice I did not say honest?

I may have not directly answered the question, but that is a tinderbox even the angry one will not touch. Best of luck to all…

30 | Oct | 2012

On Sever’s Disease

This topic–Sever’s disease–was suggested by a reader on Facebook. “Like” me on Facebook here.

To be perfectly blunt, Sever’s disease is basically the pediatric form of plantar fasciitis. Both are caused by calves that are too tight, and usually the calf contracture is silent so the person is unaware that it is present. However, the two calf contractures develop differently.

(BTW, I really don’t like Sever’s being called a disease, it just sounds so bad… We also call it Sever’s apophysitis, so that might explain why disease sticks!)

In a child, usually boys around 12-13, the calf growth does not keep pace with skeletal growth, so the calf becomes “relatively too tight.” This is why these occur just after the growth spurt. This growth differential, coupled with the “straw that breaks the camel’s back” such as recent conditioning, is what gets these started. What keeps them going is a failure to address the underlying problem—you guessed it—the relative shortened calf.

The usual treatment is rest, ice, NSAID’s, immobilization, and maybe some minor efforts at stretching. If you carefully look at the list, only one of these treatments addresses the problem.

Here is one thing I do not do. I do not shut these kids down with rest and avoid all pain mentality. This is usually a nuisance and there is no “damage” going on, so I let them participate to tolerance. Read just about any website on Sever’s and you see the alarmist mentality in action.

In the adult, plantar fasciitis is also due to calves that are too tight. However, their calf tightness is due to time and inevitable contractures that come about as we age.

In both cases, there is too much strain placed through the heel due to the calf contracture. Here is what is totally cool: both these contractures can be treated, or better yet prevented, by just stretching you calves every day…

Finally, why do my well-intentioned and learned colleagues continue to treat these things with the usual dog and pony show and ignore the calf? The problem is that they can’t wrap their head around the concept that such things as Sever’s and PF can caused by such a simple problem like calves that are too tight! I for one quit drinking that kool-aid many years ago…

23 | Aug | 2012

The Rescue Patient: Part Two

In my last blog, I coined the term “The Rescue Patient.” While I am not always successful, this experience has given me the insight to make some useful recommendations to the rescue patient who is contemplating “coming in.” Keep in mind, most of my colleagues don’t embrace this challenge.

If you fit that description, I have five tips for you before you enter my office.

1. Win over the office staff. They are your first contact and they can be your alleys or they can make it hard. Sorry, but this is the absolute truth. I love my staff and they treat our patients great, but their loyalty is to me and they protect me and the practice.

2. Do not alienate the doc immediately. Much like a rescue dog, if you lash out and bite me I will probably not take you home. I can understand, as a result of your bad experience, how you feel I might be the enemy. However, if you do want me to “take you home” and help you, you will have to bite your tongue and in some way effectively and concisely tell your story. But first, you would do well to briefly explain that you have had a bad experience and would really appreciate my help. Go ahead, suck up your pride and feed my enormous ego by buttering me up a bit.

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31 | Jul | 2012

The Rescue Patient: Part One

First and foremost I am declaring that I am the first to use this term: “The Rescue Patient.” I have now made my mark. My fifteen minutes of fame may be over.

If you can’t stomach tough love, stop reading here. If you are a rescue patient and you want to get better, read on.

You know who you are. You’ve had a bad, no, a very bad experience with the medical profession and you have lost all trust and faith. You’ve been beaten down like a political candidate. Your sensibility is destroyed and you feel you have nowhere to turn.

You feel like that spy in the movie who is being chased by everyone who is trying to “come in from the cold.” Everywhere you turn there is danger because you can’t trust anyone. Tom Cruise in Mission Impossible or Robert Redford in Three Days of the Condor comes to mind. As a result you don’t come in and you stay away. Who could blame you!

In the foot and ankle business I definitely see my share of rescue patients. From my vantage point you can be angry, contentious, controlling, and generally unpleasant. All of the ire that you did not level on the last guy is now poring out onto me. For years I did not like you. After all I am a trustworthy guy and here you are accusing and judging me, at least by implication – and we just met. You take way too much time, you are not much fun and you seem to spend all your time trying to convince me how bad this is for you.

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11 | Jul | 2012

Six Weeks: Part Two

In the last AO entry, I shared how as much as docs council our patients prior to an elective surgery, patients continue to only hear what they want to hear. Ultimately, I see these misguided — and unrealistic – expectations time and time again.

In this entry, I want to share my five simple rules to the best surgical recovery and eventual outcome.

1. Have the lowest expectations possible. The journey will always be better and who knows, you might be pleasantly surprised in the beginning, middle, and the end.

2. Listen to what you are being told and believe it, unless it seems too good to be true. You just might have yourself a used car surgeon there, professor. When we are telling you all this time-related, restrictive, terrible jibber jabber that is likely to happen, it is not CYA, it is to realign your expectations to what will actually happen. We mean it!

Several times per year a previous patient returns after they have left me to find a doc who told them what they wanted to hear. There are plenty of these docs to go around. Hey, we need the business just like the next guy and there you are, ripe for the picking. Of course there was a surgery, and that patient’s expectations were not met. Should I apologize for telling you the truth?

3. Get ready because you are about to get the ball and you need to be prepared to carry it. If you need help after surgery, get it arranged beforehand. If you are going to use crutches, get them and practice ahead of time. If you have some time constraint in the weeks/months to follow, cancel them or move your surgery.

Nothing, but nothing, pisses me off more than talking to the family immediately after surgery and being informed about a cruise they are going on in two weeks. Usually, it comes with an attitude like “what do you expect us to do about it?” You should have thought about that earlier because now YOU got the ball and you don’t want to fumble it. Come on, just a little common sense, please. It goes back to the idea they that they only hear what they want to hear.

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03 | Jul | 2012

Six Weeks: Part One

Most of us have heard of two weeks; a fortnight, 9 1/2 weeks; a racy movie, and even 26 weeks, the age of the first born child who is actually 6 months old. These “weekly” designations don’t bother me, except for the kid thing. My oldest son is 1,547 weeks old by the way.

Six weeks is the one that really bothers me. Six weeks is exactly how long it takes to recover fully from an orthopedic injury or surgery, right? Six weeks also happens to be the length of time that the average human psyche can withstand being down and not in control. Okay, that last one, the control thing, is my own semi-educated observation about my patients, but I think I am on to something here…

As much as I council my patients prior to an elective surgery, yep, you got it, six weeks is still the time that sticks in their minds. I most definitely do not put it there, but someone or something did.

This two-part blog is about the experience, the journey after surgery, not the final result. Most often these are two completely different things. Just to make sure I am clear, one could have a very rocky recovery and end up with a great result and visa versa.

Okay, a patient chooses to have an elective surgery. I have wondered and sole searched (get it?) why even after I vigorously “lay the crepe” they continue to just let it go in one ear and right out the other. Swoosh!

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08 | May | 2012

The Medical Field Gets its Act Together: Part Two

In my last post, I praise the Choosing Wisely® list, which is aimed at cutting down on unnecessary testing by docs.

I got into medicine because it is FUN, and, of course, to help people. I think most of my colleagues did so as well. I get up every day and I get to go to work and figure out puzzles all day. How cool is that? Sure, it may not always be unwarranted or a bad thing, but testing and more testing can definitely take the fun out of taking care of patients… I want to figure out your problem the old-fashioned way with a good old history and physical! Then and only then, get a test if it is warranted. This is the correct way, and the safe way, to help improve your quality of life.

So why else am I in favor of the Choosing Wisely® (and the mentality behind it)?

Our over-testing can place the patient in harms way, especially if your doctor is not vigilant. There are only three results that can come from any medical study or test. You might find what you are looking for, find nothing (negative/normal result), or a result that is unexpected. A test that shows what you are highly suspecting should be the most common result. Testing that shows nothing or is “normal” should be far and few between. Warranted screening testing or similar testing is not what I am talking about here – I am talking about a patient who has a problem for which an active diagnosis is being sought. On the other hand, we would all hope the any and all screening testing would come up normal.

Tests that show something unintended are where it can get scary folks. And this is something few ever really think about. It is sort of “beware of what you ask for.” Of course, an unintended result such as serendipitous finding an early case of early leukemia or similar is a good thing. Nobody can deny what that discovery can mean to that person and their family.

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01 | May | 2012

The Medical Field Gets its Act Together: Part One

Finally, the medical field, in general, is getting its act together. Simply put, Choosing Wisely®, the brainchild of the American Board of Internal Medicine (ABIM), is an initiative to help cut down on unnecessary medical testing. The goal behind the campaign: improve medical care by “cutting waste.” Although I suggest both doctors and patients read up on it themselves, Christine Cassel, MD – president and CEO of the American Board of Internal Medicine and the ABIM Foundation – describes Choosing Wisely® well:

“For every one of these items [on the Choosing Wisely® list of 45 overused tests and procedures], there are times when it is indicated,” she said. “We aren’t saying you should never do it — these are times you ought to have a conversation about whether you need it or not.”

At this point, this looks to be the best thing to happen in the medical field in my lifetime. Everybody benefits!

Say what you want about me: angry, arrogant, controversial, but who I really am, at my core, is a patient advocate, period. In fact, if you want to really know why I am “angry,” I fundamentally do not care for a lot of things that go on in medicine today. I have been doing this long enough to know the difference.

The four reasons why medicine is at the point it’s at today with over-testing:

• Patients ask for it!
• Testing and screening are so widely available and accessible now.
• The current insurance reimbursement structure in America lends docs, over time, to settle with the path of least resistance in dealing with patients.
• Defensive medicine

I was taught in medical school that I could come up with an accurate diagnosis greater than 90% of the time with an accurate history (as in, your story about your problem with a little of my guidance) and a physical exam. I distinctly remember hearing that and thinking to myself, “what a crock.” But today, I know this as truth. These docs today, considering the fact they can readily get that test (the one patients are ASKING for), will often bypass the effort to really learn and too quickly default to the test. As a result, one’s deeper understanding goes untapped.

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20 | Apr | 2012

DMSO, And My Question for the FDA

While DMSO is controversial, and you know I like that, this blog is really an FYI for something you have likely never heard of and you might want to know about…

DMSO — Dimethyl sulfoxide — is a byproduct of the wood pulp industry discovered in the early 1950′s. To be frank, it sounds dreadful. Have you ever smelled wood pulp at a paper mill……yuck! Yet, DMSO has been used in medicine for more than 50 years. It’s prescribed to relieve pain, to treat head injuries and strokes, for inflammation and arthritis, as an antioxidant…the list goes on and on. I am going on record to say I like this stuff and it works, in many ways. I urge you to read more about it.

Docs from Canada, Great Britain, Germany, and Japan (to name just a few), all prescribe DMSO to patients…but for those of you who don’t know, here in the US, it hasn’t been approved by the FDA.

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25 | Jan | 2012

Morton’s Neuroma: Controversial to Say the Least

What really pushed me over the edge when it came to Morton’s Neuroma (MN) was watching Steven Tyler on OWN. During his interview with Oprah (okay, I saw it with my wife – her idea!), I realized one, that he’s an awesome dude, but two, he is mislead in thinking his problem is just a MN… he showed one of his “dogs” right there on TV, and a MN, even if he has one, is the least of his worries!

First of all, a MN is not a neuroma at all… and, Morton did not describe Morton’s neuroma! What tha…? Technically speaking, it is perineural fibrosis, sort of a misplaced overgrown protective “scar” tissue surrounding and compressing an otherwise normal nerve. And this choking effect of the common digital nerve is what produces the pain. Durlacher described “Morton’s” neuroma, but I guess Morton’s neuroma sounded better. I’m certain it is easier to spell.

So, what does MN feel like? It is bottom-of-the-foot, or plantar, pain that usually comes on very slowly — months to years — and never is a result of injury or trauma. At first the pain is vague, and difficult to describe or localize, but in time, over a period of months to years, it will localize and the ability to describe the pain sharpens. You may or may not have numbness or shooting pains out into the associated toes.

Common and characteristic complaints are increased pain with tighter shoes, the urge to take ones shoe off and rub the foot, and/or the feeling that there is a fold in the sock, when there isn’t. It’s a nerve thing. The exam is defined by re-creation of the pain with palpation in the web space and possibly eliciting a pain reproducing Mulder’s click.

When I see a patient and I suspect a MN, it becomes a diagnosis of exclusion, especially if it is in the second web space. This means that all other prospects/suspects are ruled out first, usually by history and exam. BTW, a Morton’s neuroma may “feel” like swelling on the bottom of your foot, but that’s a sense that many get from numbness anywhere. However, actual, real swelling never accompanies MN. Never. The only other diagnostic test available is a diagnostic injection with or without cortisone.

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