Archive for Podiatry
Medicare Changes on Toenail Debridements
Posted by: | CommentsIn August 2011 our regional version of Medicare made significant changes in how podiatry is practiced. Unfortunately, in my opinion, it is not for the better and I feel obligated to try to explain it to my patients because there is much confusion surrounding the changes. Before I get started I want to say that these changes affect any professional that provides these services and, in fact, there are many more Medicare changes that are directed at other physicians that I am not discussing today.
In a nutshell, Medicare, in our region, no longer allows the debridement (reduction in thickness and length) of painful mycotic (fungal) toenails for otherwise healthy patients. They now require a patient to have a qualifying medical disease (list available in my office) for a patient to receive this treatment. Medicare has provided a list that reasonably contains diabetes, peripheral vascular disease, neuropathies, etc. I agree that these patients desperately need this care but I disagree that they are the only ones that need it. From the beginning of my podiatric career a patient could have their toenails debrided and their fungus treated if they were painful or limited a patient’s ability to ambulate.
I believe this is a significant change in policy for Medicare. Before this change… pain was enough to qualify for care and now pain is not enough. In my opinion, pain is not normal and requires attention that is often medical.
Additionally, Medicare has decided to reduce how often a qualifying patient may have their toenails cared for. If I remember correctly, when I began practice thirteen years ago a patient with painful fungal toenails could have them debrided every nine weeks. Then Medicare changed the frequency to every twelve weeks. Now the frequency has been changed, per my best understanding, to six times every two years, or basically every four months! Basically, the highest risk patients must wait four months to get care that may help them avoid infections, ulcerations and amputations. During a phone call, I asked the Medicare representative if she would please wait four months to trim her own toenails so she could see if this was reasonable and she said there was no way she could do that? It bothers me that she realizes that her, likely, low risk feet need more care than what Medicare is willing to provide for high risk feet.
If you are a patient of mine and have Medicare, please know that foot pain is not normal and please come and see me. Yes we are still accepting Medicare and we want to help you. Please know that most of the time your care is covered and if it is not we will discuss this with you so there are no surprises. We want to be your foot care specialist.
Please know that to my best understanding this change is currently regional so not all podiatrists are affected, yet. Typically these changes are “test driven” in a region and then many times if “successful” in lowering costs they are made nationwide. I see these changes as a bit insidious because our patients are often told their services are not being cut by Medicare but in fact they are being cut for some on Medicare. Sure the treatment is still available….but only for a more restricted list of patients and on a much more restricted schedule.
Sure, debridement of my patient’s toenails sounds like a small fish in the big ocean of healthcare. I recognize that. However, small fish like these are schooling in every medical specialty and that should concern us.
Your foot and its shape by Mark E. Sowell, DPM
Posted by: | CommentsWhen you take a step, your foot typically hits the ground heel first and rolls toward your toes, flattening the arch slightly. As you push off the ball of your foot, your arch springs back and does not touch the ground. That’s how normal feet are supposed to work. Unfortunately, many feet aren’t normal.
Overpronation occurs if your foot rolls too much toward the inside. This can cause arch strain and pain on the inside of the knee. Underpronation occurs if your foot rolls too much to the outside. Underpronation can lead to ankle sprains and stress fractures. You can relieve foot pain by compensating for these tendencies, but first you need to determine which way your feet roll.
One method for determining which kind of pronation you have is the watermark test: Put your feet into a bucket of water, then make footprints on a piece of dark paper.
•If your footprint looks like an oblong pancake with toes, you pronate excessively or may have flat feet. Try molded-leather arch supports, which can be purchased in many drug stores. And when shopping for athletic shoes, ask a sales clerk for styles with “control” features—soles designed to halt the rolling-in motion. If arch supports or sports shoes don’t help, please contact our office for a custom-molded orthotics.
•If there’s little or no connection in your footprint between the front part of the foot and the heel, you under-pronate or have a high arch. This means a lot of your weight is landing on the outside edge of your foot. Ask for “stability” athletic shoes, which are built with extra cushioning to remedy this problem. If you are prone to ankle sprains, wear high-top athletic shoes that cover the foot and ankle snugly to minimize damage from twists
Foot Pain is Not Normal – Basic Footcare Guide – Sowell Podiatry
Posted by: | CommentsBasic footcare guidelines:
Shoe Fitting Basics from Mark E. Sowell, DPM
Posted by: | CommentsI’m sure I will be writing tons of blogs over the years concerning shoes. Today I want to start off with the basics. Everything from serious foot disorders to more common foot and ankle conditions can be exacerbated by one, avoidable cause: inappropriate, poor quality, and/or ill-fitting shoes. Quality, properly fitted shoes pay big dividends for your feet—now and in the future.
The most important quality to look for in shoes is durable construction that will protect your feet and keep them comfortable. Shoes that do not fit properly can cause bunions, corns, calluses, hammertoes and other disabling foot disorders.
The Fitting
Here are some tips to help reduce the risk of foot problems when shopping for shoes:
- Don’t force your feet into a pair of shoes in order to conform to the shape of the shoe. The shoe needs to conform to the shape of your foot.
- Fit new shoes to your largest foot. Most people have one foot larger than the other.
- Have both feet measured every time you purchase shoes. Foot size increases as you get older.
- If the shoes feel too tight, don’t buy them. There is no such thing as a “break-in period.”
- Many high-heeled shoes have a pointed or narrow toe box that crowds the toes and forces them into an unnatural triangular shape. As heel height increases, the pressure under the ball of the foot may double, placing greater pressure on the forefoot as it is forced into the pointed toe box. Limit heel height to two inches or less to protect your feet.
- Shoes should be fitted carefully to your heel as well as your toes.
- Sizes vary among shoe brands and styles. Judge a shoe by how it fits on your foot, not by the marked size.
- There should be a half-inch of space from the end of your longest toe to the end of the shoe.
- Try on new shoes at the end of the day. Your feet normally swell and become larger after standing or sitting during the day, which makes for a better fit.
- Be sure to try on both shoes. Walk around the shoe store in the shoes to make sure they fit well and feel comfortable.
- When the shoe is on your foot, you should be able to freely wiggle all of your toes.
Retrocalcaneal Bursitis – Heel Pain in Nacogdoches – Sowell Podiatry
Posted by: | CommentsI recently posted a foot pain discussion of Achilles tendonitis that I feel helps a patient suffering with pain on the back of the heel understand what might be going on. However, there is a diagnosis in the same anatomic area that often gets confused with Achilles tendonitis and I thought I should discuss it today. Retrocalcaneal bursitis refers to a fluid filled sac (bursa) that rests behind (retro) the heel bone (calcaneal). This bursa has the unenviable job of cushioning between the heel bone and the Achilles tendon. When this bursa becomes inflamed we call it bursitis.
As a podiatrist in Nacogdoches Texas, I see all types of patients with this painful condition but there is one type I seem to see more than others. This patient, I think, makes a good example for our discussion and should help us better understand the condition. I am speaking of the newly retired cowboy! Lol. This patient has worn cowboy boots for fifty years, usually with a pretty good heel on them, and has now retired from his work where the boots were required. So, he has begun wearing tennis shoes more and unknowingly began a mechanical condition that will lead to pain.
After years of wearing an elevated heel in a shoe, or boot, the tendon becomes adjusted to the length needed in that particular shoe. Over years it can become much shorter and if not stretched properly over those years it can have significant difficulty adjusting to its new environment in a tennis shoe. As the heel gets lower, the pressure between the tendon and heel bone increases and the bursa becomes irritated. I also see this in athletes who have been making their calf muscles bigger but not stretching them properly.
Treatment, after proper diagnosis, usually consists of ice, NSAIDS, physical therapy or steroid injections for the swelling and at some point will include a stretching program to lengthen the tendon. Heel pads and lifts have also been proven to help the situation. Of course, proper assessment is the key and is why I feel a podiatrist is necessary in all conditions concerning the heel.
My Favorite Patient Story
Posted by: | CommentsWhen I was a new podiatrist in East Texas it was not uncommon to have a patient sit in my chair and compare me to their last podiatrist. For a new doctor you can imagine this was a bit unsettling because one is never sure how he measures up to the “competition”. Anyway, I’ll never forget my 85 year old patient who had decided to try out the “new guy” after years of driving to Shreveport to see her regular podiatrist. Curious about the podiatrist in Shreveport, I asked what he was like:
“Well”, she said, “He is very good. He is very gentle and very nice to talk to. He seems to be very knowledgeable and knows exactly what to say and when to say it. Oh, and he has wonderful hands. You can barely tell when he is working on you.” She continued’ “ His hands are incredibly soft and his fingers were long and tapered just so.” “I told him once that his hands were so nice they belonged on a woman” she exclaimed.
I asked her what his response was.
She said his reply was, “Sometimes they are!”
Lol, that is one of my favorite patient stories and is as true as I can remember it. I’ll bet he was a good podiatrist with a sense of humor like that.
