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liveonearthJohn Hahn DPM ND speaking
Podiatric Medicine-Naturopathic Family Practice
notes include nice overview of common foot conditions
bald guy, I see from his CV he graduated undergrad the year I was born
he looks pretty strong, healthy, wearing a cream shirt and khaki pants
NCNM graduate of 1992
was already a podiatrist, 4 yr degree prereq, 4 year program, surgical residency rqd
why feet? "I flunked knees"
what do you do with your feet?
allo doc: "we watch 'em turn gangrenous and then we amputate 'em"
not many people going into podiatry, demand is increasing
AGING POPULATION
boomers aging
in 2003 20% of US pop over 65 years of age
some competition among podiatrists
he says more docs-->more awareness, "top of mind awareness"
lots of other practitioners do some foot procedures
ingrown toenail surgery
DIABETES EPIDEMIC
number in US passing 18 million
Natives and Mexicans have disproportionate share of morbidity and mortality dt foot complications
prediabetic conditions mb revealed by feet
peripheral vascular disease revealed there and in eye
goal: prevent amputations
PODIATRIC PRACTICE PATTERNS
mostly solo but trend toward group practices, some in hospitals
(average overhead for solo practitioner is 75% in PDX area)
150-250 pts/week, 25-30 are procedures
2-6 employees
new pt visit $114-225
more elders in warmer climates, retirement communities
shifting medicare allocation changes demographics
some pts will pay cash, most pts purchase products not covered by insurance
bunion pads, arch supports
routine foot care: trimming, bunions
COMMON CONDITIONS & ICD9
plantar fasciitis 728.71
hammertoes 735.4
corns/calluses 700
diabetic ulcers 250.8
onychocryptosis (ingrown toenails) 703.0
onychomycosis 110.1
tinea pedis 110.4
diabetic peripheral neuropathy 250.6
peripheral vascular disease 443.9
neuromas 355.6
bunion deformity 727.1
onychauxis 703.8
PLANTAR FASCIITIS
728.71
pts usu over 25 BMI
flat footed and heel bone everted into valgus position
becomes chronic in 5-10% of pts
over 90% resolve with conservative tx
pain usu where plantar fascia attaches to heel bone
pain on standing esp after inactivity
may feel better in high heel to a point,
then when big toe bent back enough to tighten fascia, worse again
may form bone spur where inflam is
DDX FOR HEEL PAIN: calcaneal apophysitis (kids), arthritis, gout, Reiter's (Lover's Heels), stress fx, achilles tendon prob, bone cyst, pinched nerve/nerve entrapment, low back or disk problems incl spondylolisthesis at L4-5
DX: pain w/ press on bottom of heel or arch, limping, foot type: low arch, pronation, xray: spur? ultrasound, nerve conduction velocity study?
TX: mechanical: tx cause, anti-inflam: tx pain
TX: stretch, shoe mod, avoid barefoot, icing, rest, splinting, arch support, antiinflam meds, steroid injx, PT, surgery as last resort
TX: I have seen: prolotherapy, herbal anti-inflam, acupuncture, tennis ball rolling
TX: He does traumeel injections mixed 50-50 with 1/2% marcaine plain, injected into medial plantar fascia band, uses PT block instead
TX: He has used botox, Btx-A (allergan) of 50 units injx into abductor hallucis and around plantar fascia, disrupts nerve signalling and blocks acetylcholine, action sim to substance P, lasts 6-8 mo, one unit of botox is $520 so tx is costly
TX: extracorporeal shock wave therapy ESWT, autologous platelet concentrate APC injx, cryosurgery, radiofrequency techniques, no one therapy 100% successful
TX: wt loss
BUNION DEFORMITIES
727.1
autosomal dominant incomplete penetrance
incidents 1.92% or 1/51 people
5.2 million in US
= enlargement of joint, can cause toes to twist over each other
MTP joint mb stiff/sore or asx
bunion mb just behind little toe
hard/firm bump on inside edge of foot by 1st MTPJ
progressive in nature, sx of faulty foot fx, way of walking, inherited foot type, shoes
etio: foot injuries, neuromuscl, congenital, tight shoes, flattened shoes, arthritis, gout, pedagra
DX: consider x-rays
TX: padding, taping, bracing, meds, PT, orthotics, different shoes
Tx: surgery to remove bony enlargemnt, simple bunionectomy, head procedures, base procedures, joint replacements
Tx: recuperation takes time, a year to heal bone changes, pain managed with meds
BAREFOOT ASIDE
barefooted walking and running
current fad, would be good if world wasn't paved
does strengthen feet
he likes kids to live out of shoes as long as possible
HAMMERTOE DEFORMITIES 735.4
toes curled, contracted, bending at 1st interphalangeal
if at distal joint then a mallet toe
more in women dt shoes
mostly 2nd-5th toes
pain on top of bent toe
corns may form
red/swollen joint, restricted movement
abn muscle balance
TX: pad, tape, splint, meds, cortisone
TX: tendon release, bone remodeling, removing bones, fusion of joints
TX: recuperation takes long time, little toes especially, careful with shoes
INGROWN TOENAILS
703.0
more in men
2.6^ or 1/38
7.1 million people afflicted
omega shaped nails dt poor trimming
OSTEOARTHRITIS
715.97
7.35% incidence, 1/13
20million
CORNS AND CALLUSES
700.0
2.5%, 1/40 people
6.8 million people
dt abn pressure or friction, shoes, bonions, gait abnormalities
self tx not recommended dt risk of burns, self-cutting, infx
beware of black salve for diabetics
aside: look in drug store at all the feet products
everybody's a surgeon on their own feet
HEEL FISSURES
709.8
worse with thick skin
etio: standing, obese, sandals, DM, low thyroid, eczema, psoriasis,
excessive wetness/sweating, dry climate
TX: debride to pink skin and fill crack with superglue
TX at home: pumice stone, avoid hot bath/shower, emollient, weight loss
WARTS
078.10
viral growths
may be buried in sole of foot: plantar wart
mosaics large and flat, black specks are clots in capillaries
try graphites orally
no cure, amputate part is 100%
duct tape
TX: He uses cryotherapy and microdissection to remove.
TINEA PEDIS
110.4
athlete's foot, two trichophytons and one other sp
DDX: lichen planus (look in mouth), eczema
TX: antifungals topical or oral, drying agents, changes in footwear and sox
Prevent: avoid barefoot, use foot powder, changes shoes often, wear breathable footwear
keep feet dry
To resurrect shoes: prewash with bleach then put mothballs in them, dry thoroughly
CHILBLAINS
991.5
vasospastic disorder, small BVs in skin constrict forming painful red-blue lesions on skin
more in pts with poor circ and in cold/humid climates
TX: move to Hawaii
more in girls and older women
Tx: ginkgo, niacin
TX: stop smoking
PITTED KERATOLYSIS
dt bacterial infx
foul odor
discrete pits in plantar tissues of toes and feet
grows in moist
benzylperoxide, clindamycin, benzacline
changes shoes & sox
PSORIASIS
696.8
in toenails: thickened pitted disfigured mails, inflam around
Dx: do KOH for fungus to be sure it's not
DX: auspitz sign is blood spots under scale
DxL pencil and cup changes in joints
correl w/ stress
Tx: sun
Tx: many drugs
guttate psoriasis right above butt cleavage
Tx: cortisone, sun, baths, moisturizers, nail trimming
ECZEMA/ATOPIC DERMATITIS
692.9
itchy, scaly
etio: unknown
common in kids but may persist
mb w/ asthma, hay fever
usu at arms and legs but mb anywhere
Tx: cream w/ lavendar, eladil = NSAID
ONYCHOMYCOSIS
110.1
ETIO: trauma, DM, circ dz, immunodef, genetic
SX: thick, discolored nails, foul smell, debris under toenail
complic: subungual abscess-->osteomyelitis
Tx: debridement, topicals, oral meds, nail avulsion,
pinpoint laser therapy (80% cure rate, 5 treatments, $550/tx, no long term studies yet)
INGROWN TOENAILS
703.0
etio: inherited, trauma, pressure, improper trimming
Home TX: soak w/ salt, topical abx, avoid trimming nail
Pod Tx: trimming, oral abx, surgical excision of involved nail borders
Prevention: proper trimming "straight across" not too shore, room in shoes
THINGS HE TXS W/ HOMEOP INJX
sprain, strain
plantar fasciitis
neuroma
tendonitis esp achilles (steroids cause softening of tissue and possible rupture)
pre and post op
bursitis
capculitis
he says stuff heals 50% faster
gives oral homeop 7-10 days preop, 1tid
continues post op
revenue enhancement for physician without insurance billing (tx is inexpensive)
MORTON'S NEUROMAS
thickening of 3rd intermetatarsal nerve, btw 3 & 4th toes
pain on wt bearing
Tx: wide shoes, orthotics, metatarsal pads, US
Tx: surgical removal and/or neurolysis and redirection, bring nerve up
Alt tx: perinerual injx w/ traumeel and marcaine
DIABETIC ULCERS
250.8
may not be painful or bleeding but may be terribly gory
Tx: debridement, wound closure
Tx: elizeroth frame = external fixation with pins to hold bone in place
Tx: less amputation these days
Tx: work with many docs, wound care specialist
Tx: special shoes
DIABETIC PERIPHERAL NEUROPATHY
356.9
insurance will pay to remove limbs but not to save them
nerve dmg dt DM prevalent
NO pathways deranged
mc type of neuropathy is sensory motor
metformin: incr test, decr B12/folate-->incr homocysteine
60-70% of foot ulcers are preceded by neuropathy
85% of diabetes related limb amputat preceded by foot ulcer
3/10 with amputat will losse another limb within 3 years and high fraction will die
old method for determining where to amputate: where limb begins to bleed
Dx: tuning fork on toes, feet
Sx: decr DTRs, loss of pain sensation, numb, prickly/tingling/burning pain
Sx: loss of hair on toes, lower legs
Sx: psych morbidity: depression, anger, anxiety, loss of self-esteem
Sx: majority of DPN pts are insensate
TX: alpha lipoic acid, Lcarnitine, fish oil, B6
Dx: biosthesionmeter
Dx: nerve conduction studies usu not ordered
Dx: new: IENFD skin biopsy, 3mm punch to look at nerve fiber density
Tx: missed the drugs
Tx: glucose control, new pancreas
Tx: antiox: ALA 1200-1800mg orally
(plus carnitine, helps short memory and reverses diabetic neuropathy)
Tx: neurotrophic support: L-methylfolate, P5P, Me-Cbl (Metanx by Pharmlabs) product he likes
this helps with elevated homocysteine dt metformin
GOOD NEWS: nerve density can be restored, sensitivity can return
he does traumeel injx for knee issues
chondromalacia patella
Podiatric Medicine-Naturopathic Family Practice
notes include nice overview of common foot conditions
bald guy, I see from his CV he graduated undergrad the year I was born
he looks pretty strong, healthy, wearing a cream shirt and khaki pants
NCNM graduate of 1992
was already a podiatrist, 4 yr degree prereq, 4 year program, surgical residency rqd
why feet? "I flunked knees"
what do you do with your feet?
allo doc: "we watch 'em turn gangrenous and then we amputate 'em"
not many people going into podiatry, demand is increasing
AGING POPULATION
boomers aging
in 2003 20% of US pop over 65 years of age
some competition among podiatrists
he says more docs-->more awareness, "top of mind awareness"
lots of other practitioners do some foot procedures
ingrown toenail surgery
DIABETES EPIDEMIC
number in US passing 18 million
Natives and Mexicans have disproportionate share of morbidity and mortality dt foot complications
prediabetic conditions mb revealed by feet
peripheral vascular disease revealed there and in eye
goal: prevent amputations
PODIATRIC PRACTICE PATTERNS
mostly solo but trend toward group practices, some in hospitals
(average overhead for solo practitioner is 75% in PDX area)
150-250 pts/week, 25-30 are procedures
2-6 employees
new pt visit $114-225
more elders in warmer climates, retirement communities
shifting medicare allocation changes demographics
some pts will pay cash, most pts purchase products not covered by insurance
bunion pads, arch supports
routine foot care: trimming, bunions
COMMON CONDITIONS & ICD9
plantar fasciitis 728.71
hammertoes 735.4
corns/calluses 700
diabetic ulcers 250.8
onychocryptosis (ingrown toenails) 703.0
onychomycosis 110.1
tinea pedis 110.4
diabetic peripheral neuropathy 250.6
peripheral vascular disease 443.9
neuromas 355.6
bunion deformity 727.1
onychauxis 703.8
PLANTAR FASCIITIS
728.71
pts usu over 25 BMI
flat footed and heel bone everted into valgus position
becomes chronic in 5-10% of pts
over 90% resolve with conservative tx
pain usu where plantar fascia attaches to heel bone
pain on standing esp after inactivity
may feel better in high heel to a point,
then when big toe bent back enough to tighten fascia, worse again
may form bone spur where inflam is
DDX FOR HEEL PAIN: calcaneal apophysitis (kids), arthritis, gout, Reiter's (Lover's Heels), stress fx, achilles tendon prob, bone cyst, pinched nerve/nerve entrapment, low back or disk problems incl spondylolisthesis at L4-5
DX: pain w/ press on bottom of heel or arch, limping, foot type: low arch, pronation, xray: spur? ultrasound, nerve conduction velocity study?
TX: mechanical: tx cause, anti-inflam: tx pain
TX: stretch, shoe mod, avoid barefoot, icing, rest, splinting, arch support, antiinflam meds, steroid injx, PT, surgery as last resort
TX: I have seen: prolotherapy, herbal anti-inflam, acupuncture, tennis ball rolling
TX: He does traumeel injections mixed 50-50 with 1/2% marcaine plain, injected into medial plantar fascia band, uses PT block instead
TX: He has used botox, Btx-A (allergan) of 50 units injx into abductor hallucis and around plantar fascia, disrupts nerve signalling and blocks acetylcholine, action sim to substance P, lasts 6-8 mo, one unit of botox is $520 so tx is costly
TX: extracorporeal shock wave therapy ESWT, autologous platelet concentrate APC injx, cryosurgery, radiofrequency techniques, no one therapy 100% successful
TX: wt loss
BUNION DEFORMITIES
727.1
autosomal dominant incomplete penetrance
incidents 1.92% or 1/51 people
5.2 million in US
= enlargement of joint, can cause toes to twist over each other
MTP joint mb stiff/sore or asx
bunion mb just behind little toe
hard/firm bump on inside edge of foot by 1st MTPJ
progressive in nature, sx of faulty foot fx, way of walking, inherited foot type, shoes
etio: foot injuries, neuromuscl, congenital, tight shoes, flattened shoes, arthritis, gout, pedagra
DX: consider x-rays
TX: padding, taping, bracing, meds, PT, orthotics, different shoes
Tx: surgery to remove bony enlargemnt, simple bunionectomy, head procedures, base procedures, joint replacements
Tx: recuperation takes time, a year to heal bone changes, pain managed with meds
BAREFOOT ASIDE
barefooted walking and running
current fad, would be good if world wasn't paved
does strengthen feet
he likes kids to live out of shoes as long as possible
HAMMERTOE DEFORMITIES 735.4
toes curled, contracted, bending at 1st interphalangeal
if at distal joint then a mallet toe
more in women dt shoes
mostly 2nd-5th toes
pain on top of bent toe
corns may form
red/swollen joint, restricted movement
abn muscle balance
TX: pad, tape, splint, meds, cortisone
TX: tendon release, bone remodeling, removing bones, fusion of joints
TX: recuperation takes long time, little toes especially, careful with shoes
INGROWN TOENAILS
703.0
more in men
2.6^ or 1/38
7.1 million people afflicted
omega shaped nails dt poor trimming
OSTEOARTHRITIS
715.97
7.35% incidence, 1/13
20million
CORNS AND CALLUSES
700.0
2.5%, 1/40 people
6.8 million people
dt abn pressure or friction, shoes, bonions, gait abnormalities
self tx not recommended dt risk of burns, self-cutting, infx
beware of black salve for diabetics
aside: look in drug store at all the feet products
everybody's a surgeon on their own feet
HEEL FISSURES
709.8
worse with thick skin
etio: standing, obese, sandals, DM, low thyroid, eczema, psoriasis,
excessive wetness/sweating, dry climate
TX: debride to pink skin and fill crack with superglue
TX at home: pumice stone, avoid hot bath/shower, emollient, weight loss
WARTS
078.10
viral growths
may be buried in sole of foot: plantar wart
mosaics large and flat, black specks are clots in capillaries
try graphites orally
no cure, amputate part is 100%
duct tape
TX: He uses cryotherapy and microdissection to remove.
TINEA PEDIS
110.4
athlete's foot, two trichophytons and one other sp
DDX: lichen planus (look in mouth), eczema
TX: antifungals topical or oral, drying agents, changes in footwear and sox
Prevent: avoid barefoot, use foot powder, changes shoes often, wear breathable footwear
keep feet dry
To resurrect shoes: prewash with bleach then put mothballs in them, dry thoroughly
CHILBLAINS
991.5
vasospastic disorder, small BVs in skin constrict forming painful red-blue lesions on skin
more in pts with poor circ and in cold/humid climates
TX: move to Hawaii
more in girls and older women
Tx: ginkgo, niacin
TX: stop smoking
PITTED KERATOLYSIS
dt bacterial infx
foul odor
discrete pits in plantar tissues of toes and feet
grows in moist
benzylperoxide, clindamycin, benzacline
changes shoes & sox
PSORIASIS
696.8
in toenails: thickened pitted disfigured mails, inflam around
Dx: do KOH for fungus to be sure it's not
DX: auspitz sign is blood spots under scale
DxL pencil and cup changes in joints
correl w/ stress
Tx: sun
Tx: many drugs
guttate psoriasis right above butt cleavage
Tx: cortisone, sun, baths, moisturizers, nail trimming
ECZEMA/ATOPIC DERMATITIS
692.9
itchy, scaly
etio: unknown
common in kids but may persist
mb w/ asthma, hay fever
usu at arms and legs but mb anywhere
Tx: cream w/ lavendar, eladil = NSAID
ONYCHOMYCOSIS
110.1
ETIO: trauma, DM, circ dz, immunodef, genetic
SX: thick, discolored nails, foul smell, debris under toenail
complic: subungual abscess-->osteomyelitis
Tx: debridement, topicals, oral meds, nail avulsion,
pinpoint laser therapy (80% cure rate, 5 treatments, $550/tx, no long term studies yet)
INGROWN TOENAILS
703.0
etio: inherited, trauma, pressure, improper trimming
Home TX: soak w/ salt, topical abx, avoid trimming nail
Pod Tx: trimming, oral abx, surgical excision of involved nail borders
Prevention: proper trimming "straight across" not too shore, room in shoes
THINGS HE TXS W/ HOMEOP INJX
sprain, strain
plantar fasciitis
neuroma
tendonitis esp achilles (steroids cause softening of tissue and possible rupture)
pre and post op
bursitis
capculitis
he says stuff heals 50% faster
gives oral homeop 7-10 days preop, 1tid
continues post op
revenue enhancement for physician without insurance billing (tx is inexpensive)
MORTON'S NEUROMAS
thickening of 3rd intermetatarsal nerve, btw 3 & 4th toes
pain on wt bearing
Tx: wide shoes, orthotics, metatarsal pads, US
Tx: surgical removal and/or neurolysis and redirection, bring nerve up
Alt tx: perinerual injx w/ traumeel and marcaine
DIABETIC ULCERS
250.8
may not be painful or bleeding but may be terribly gory
Tx: debridement, wound closure
Tx: elizeroth frame = external fixation with pins to hold bone in place
Tx: less amputation these days
Tx: work with many docs, wound care specialist
Tx: special shoes
DIABETIC PERIPHERAL NEUROPATHY
356.9
insurance will pay to remove limbs but not to save them
nerve dmg dt DM prevalent
NO pathways deranged
mc type of neuropathy is sensory motor
metformin: incr test, decr B12/folate-->incr homocysteine
60-70% of foot ulcers are preceded by neuropathy
85% of diabetes related limb amputat preceded by foot ulcer
3/10 with amputat will losse another limb within 3 years and high fraction will die
old method for determining where to amputate: where limb begins to bleed
Dx: tuning fork on toes, feet
Sx: decr DTRs, loss of pain sensation, numb, prickly/tingling/burning pain
Sx: loss of hair on toes, lower legs
Sx: psych morbidity: depression, anger, anxiety, loss of self-esteem
Sx: majority of DPN pts are insensate
TX: alpha lipoic acid, Lcarnitine, fish oil, B6
Dx: biosthesionmeter
Dx: nerve conduction studies usu not ordered
Dx: new: IENFD skin biopsy, 3mm punch to look at nerve fiber density
Tx: missed the drugs
Tx: glucose control, new pancreas
Tx: antiox: ALA 1200-1800mg orally
(plus carnitine, helps short memory and reverses diabetic neuropathy)
Tx: neurotrophic support: L-methylfolate, P5P, Me-Cbl (Metanx by Pharmlabs) product he likes
this helps with elevated homocysteine dt metformin
GOOD NEWS: nerve density can be restored, sensitivity can return
he does traumeel injx for knee issues
chondromalacia patella
