Question: I have been listening to all the talk about changing the educational requirements to a two-year Associate's Degree.  While I agree that the requirements need to be changed, I have one question for thought.  Why would one want to go to two years of education to become a C. Ped. to work basically on the foot and ankle when in the same two years of education, you can become an Orthotist?  This field opens the doors to more modalities that can be done, and the potential to making more money.  Then I have another question.  What will happen to the Pedorthic field?  Some questions for thought!  The future of Pedorthics is at hand.

- Jim Murray C. Ped.

Question: Every once in a while a client returns a full-length carbon fiber foot plate because it is fractured. What are the conditions you have found to cause this to happen? What are the preventions?

- Robert S. Schwartz, C. Ped., Eneslow Pedorthic Enterprises, Inc.

Comment: I certainly enjoy the insight and comments of the Pedorthic community in the Pedorthic Newswire issues.  You provide a much needed resource and forum for professional opinions and learning.

I must, however respond to a recent article under your Diabetes section titled "Socks and the Diabetic" written by Mr. Michael Smoker (pen name).  In the article, Mr. Smoker attempts to inform your audience by providing "a list of the things to consider if you have diabetes and are looking for the right sock".  Unfortunately, the information Mr. Smoker provides shows his lack of knowledge about the important role socks play in the overall foot health of these patients. 

Mr. Smoker's biography on Helium states "I've been writing off-and-on for 35 years, and have acquired a broad range of general knowledge that makes general interest nonfiction fairly easy for me to put together..." 

Unfortunately, socks are not included for reimbursement under the Medicare Shoe Bill and there is no regulation as to what type of sock can be labeled "appropriate for diabetics."  This had led to a wide range of inappropriate products being recommended and sold by people who do not fully understand that the consequences of a poor selection can lead to extreme complications.  Many Pedorthic practices concentrate on billable product and don't fully appreciate how important a role that a pair of well fitting, high performance socks has in the entire fit system being recommended by the Pedorthist.  Unlike "an ordinary store bought a sock that costs much less" being recommended by Mr. Smoker, a well-constructed pair of socks, made from high performance fibers with the attention to quality and function is significantly more difficult and expensive to manufacture than a discounted alternative. 

Mr. Smoker advises to "avoid polyester socks," and that "a cotton blend is usually the best choice."  This further demonstrates his lack of knowledge about the advances in modern performance fibers.  A good moisture managing synthetic yarn is designed to wick moisture away from the foot through capillary action across the surface of the fibers while maintaining its cushioned protectiveness.  Although cotton absorbs great, it doesn't release moisture once it is saturated.  Cotton also loses its cushioning ability when wet, and creates the perfect environment in the shoe to create blisters. 

There are also many misconceptions and misinformation about anti-bacterial and anti-microbial treatments on fabric.  While there are some effective treatments both through topical treatment and by use of fibers with additives inherent with the fiber itself available to control odor by inhibiting the growth of bacteria on the surface of the fabric, there are large variations of effectiveness and efficacy depending upon the application.  While the marketing of these treatments many times imply that the treatment will migrate to the surrounding skin and provide benefits greater than what actually happens, the EPA has recently begun scrutinizing these claims and issuing fines for false and misleading advertising.

A well-constructed sock will fit close to the skin without bunching, wrinkling, or falling down even after a long day of walking and wearing.  Handlinked seamless toe closures eliminate the rough toe seam that is present in "ordinary" socks and, although very more expensive to manufacture, are critical to a patient suffering from neuropathy who may not feel a rough spot in his footwear.  Also to be considered is how the volume of the protective cushion will affect the fit of the shoe and orthotic being recommended.  Some patients may require extra cushion in specific areas of the sock, while reduction of sheer friction may be the requirement for other patients.

The goal of Pedorthists should be to provide the best "system" of protection and performance for your customers.  Socks provide the all-important interface between your skin and your footwear and should never be overlooked or under valued.

- Rob Zellmer, General Manager, Doctor Specified

Editor's Note:  Thank you for pointing out the inaccuracies in the article we linked to, and for furthering the cause of educating our readers about the appropriate treatment, footwear, and socks for diabetic patients.  After reading your letter I did some research to try to find a comprehensive, more reputable published article about diabetic socks, and I was surprised at the differing recommendations in the media in the very few articles that I could find.  The American Diabetes Association also had limited information on their website.

Question: We have Medicare questions needing clarification by PNW readers:

1) Medicare states that the physician must confirm that the patient meets the criteria for the Therapeutic Shoe Bill. I understand all the diagnoses/requirements but the "poor circulation one." There is no ICD9 diagnosis for "poor circulation." Therefore, I am looking for insight into whether a "congestive heart failure" would imply "poor circulation" and would be acceptable to Medicare (in your opinion) or any other systemic diseases that we can "assume has poor circulation because of the diagnosis."

2) Does the pedorthic community believe that a "hammertoe, mallet toe or claw toe" meets Medicare's criteria of "foot deformity?" If a misshaped digit of this nature can meet the criteria for "foot deformity," then can a curly toe, medially or laterally deviated digit upon its long axis, also be considered a "foot deformity?" Is an everted calcaneus considered a "foot deformity?"

3) I remember the day when Janis Gregory, who is now considered "our pedorthic expert on Medicare," was our mentor.  I would be interested in discussing how we might put together a short PPT on this topic to aid in our students' understanding, and most importantly to ensure that we are compliant in our internship program as we enter nursing homes to provide pedorthic services.

- Pam Haig, C. Ped., RMPI Pedorthics School

Response: Regarding the question of what meets CMS's understanding of "poor circulation in either foot": We use the ICD-9 code of 250.70, which according to the ICD-9 coding book is "diabetes with peripheral circulation disorder." As far as what constitutes a foot deformity (736.70), in the absence of any specific guidance from CMS, we consider as deformities hammertoes, malleted toes, mis-shaped digits, marked rear, mid or forefoot varus or valgus abnormalities or any other legitimate foot architecture that could cause unusual foot weight-bearing. I don't believe there is ICD-9 coding for "history of previous ulceration of either foot" or "history of pre-ulcerative callus of either foot," but that doesn't mean that the certifying physician won't recognize such histories and, according to new CMS standards, have that information written within the physician's patient notes and therefore be able to certify therapeutic footwear and inserts as being medically necessary for a given patient. Hope this helps.

- James Garner, R.Ph., C. Ped., C.O., ActivMedical, Denton, TX

Response: CHF is caused by poor left ventricular function, or left side heart muscle failure. CHF, in my opinion, is a stretch for poor circulation. I believe that the only way to prove that a person has poor circulation is by ankle brachial index, or a diagnosis of peripheral arterial disease, PAD. Ultimately, poor circulation is the only reason that a person will develop a foot ulcer. A foot deformity coupled with good circulation will not result in a foot ulcer. But a foot deformity with "poor circulation" is very dangerous. 

 - Antonio Davila BSN, RN, C. Ped.

Response:According to Dr. Merton Root, the pioneer in foot biomechanics, the four criteria for foot normalcy are:

1.      Absence of pain

2.      Normal muscle balance

3.      Vertical heel (debatable)

4.      Straight and mobile toes

By Dr. Root's criteria a hammer/mallet/curly toe(s) is a foot deformity.

- Aaron Anderson, C. Ped., P.T.I. Orthotic Laboratory, Boulder, CO

Comment: The new rules on a patient receiving therapeutic shoes within 6 months of seeing the doctor sets the stage for unintended consequences and real risk to the DME.  I agree that the patient should see the Doctor and that the Doctor should document in the patient's chart those conditions warranting therapeutic shoes, and subsequently write an order before 6 months has transpired.  However, the rule to do so 6 months before delivery is problematic.

SCENARIO:

1.  Patient sees the Doctor on October 2, 2010.

2.  Doctor notates PVD along with an RX for Plavix in the patient's chart.

3.  Patient calls DME requesting Therapeutic Shoes for 2011 on March 1st, 2011.

4.  DME faxes Dr. requesting a CMN and RX on the patient's behalf that same day.

5.  Physician reviews the chart, certifies the patient under poor circulation, and writes an RX for shoes and inserts and faxes the CMN and the RX to DME on March 10, 2011.

SO FAR SO GOOD

THE PATIENT WAS SEEN BY THE DOCTOR AND DR. DOCUMENTED PVD WITHIN THE LAST 5 MONTHS

THE DOCTOR PROVIDED THE CMN AND THE RX BEFORE 6 MONTHS HAD PASSED.

However, the initial visit to measure feet, do an assessment, order shoes and custom inserts and complete a final fitting before 6 months has not occurred.

The DME performs the initial fitting, does an assessment, orders the shoes and inserts, receives the product and calls the patient to perform a final fitting.  At that time, the patient doesn't like the shoes or the shoes do not fit properly.

By the time new shoes are reordered and a new final fitting is scheduled, the 6-month window of delivery from the physician visit has run out.  The DME tells the patient that Medicare rules now require them to see their doctor again before they can get their shoes.  The patient has to schedule another appointment and the doctor has to enter new documentation and write a new CMN plus a new prescription in order for the patient to receive his shoes.

The doctor faxes a new CMN and RX to the DME after the patient makes a special trip to the doctor to obey the rules.  The doctor fails to re-note in the patients chart documentation that the patient needs shoes and inserts due to PVD.  The rule requires documentation after the patient's new visit, even though the patient still has PVD and still needs shoes and inserts.

Upon audit, the DMEMAC requests recoupment because the Dr.'s notes to not meet the requirement of the rule. The patient has been inconvenienced, the doctor has made a new billing to Medicare for an office visit, and the DME has entered a bill that fails to dot all the i's and t's and has to repay the money.  The patient gets to keep the shoes, the Dr. gets an additional office visit, and the DME gets screwed.  I see this as a nightmare for the DME and a rule that was issued without any comment from the providers of this service.

A simple solution, would be as follows:

1.  The patient must see the Doctor and the Doctor must certify for therapeutic shoes, document in the patients chart medical necessity for conditions certified, and write an RX within 6 months of the patient's visit.

2.  The DME must perform the final fitting no later than 90 days from the date of the order.

In my opinion, this would satisfy CMS desires and prevent the DME from entering a Catch-22 when shoes are ordered too close to the 6 month rule.

- PNW Reader

Response:I believe that a much more sensible way is that once you produce a progress note, that progress note should be valid for the life of the patient. Once a patient is diagnosed with a neuropathy, foot deformity, poor circulation, pre-ulcerative callus, or history of amputation, those are permanent conditions. Why would CMS risk amputation to save essentially pennies at the risk of a costly amputation? It makes NO sense. 

-  Antonio Davila BSN, RN, C. Ped.

Comment: I received a mailer today from the PFA regarding board nominees and voting for the 'Class of 2012 PFA Board of Directors', and it reminded me of a recent response submitted by Shane Hayes, C. Ped., in the August 18, 2010 PNW Issue #378, and its relativity to the upcoming PFA elections.

Faith Ballard, C. Ped., 2010 Nomination Committee Chair writes in the PFA letter on behalf of the Nomination Committee; " Every attempt has been made to provide a balance of representations by selecting pedorthic professionals who represent a variety of pedorthic affiliations, differing geographic locations, cross credentials and strong depths of experience in the various activities of PFA. I am grateful to the entire PFA Nomination Committee for their conscientious work."

Of the 5 nominees listed for consideration, 4 have/have had extensive involvement with the PFA in some capacity or another, or are current board members. How far does the nominating committee look for its nominees, across the table? As far as differing geographic locations, there are States and qualified PFA practitioners West of the Mississippi! Why does a nominee need 'strong depths of experience in the various activities of PFA'? What's wrong with youthful exuberance and fresh ideas?

Mr. Hayes recent critique of John Mishasek, C. Ped's,  'puerile' comments included the following statement; "I would propose that those C. Peds with limited skills set a new goal to get seriously involved in pedorthics, expand their skill/educational base, and maybe even run for the board to actually make a difference; verses standing in the corner talking loud." I agree with Mr. Hayes on this point. However, it seems the PFA has different criteria (see above), preferring to select from members of its inner circle that have consistently supported the same PFA mantra. Would those that talk loud and are willing to volunteer ever be considered?

I applaud those who volunteer for leadership positions within our allied organizations; ABC, BOC, PFA, CAPE, COPE, etc., and AM IN NO WAY QUESTIONING THE CREDENTIALS, NOR THE WELL INTENDED COMMITMENT, OF THE PEOPLE NOMINATED OR THOSE CURRENTLY IN OFFICE.

In my opinion, the PFA could look a little further for new volunteers, fresh ideas, and a larger selection of nominees, in an effort to ameliorate our PFA, the member's organization, during these difficult economic times.

- Gordon Rabing, C. Ped.

Response: I wholeheartedly agree with Mr. Rabing's response concerning the 2012 PFA Board of Director's selections. We certainly do not want the PFA to become akin to our country's esteemed political parties, espousing ideas in lockstep with one another, and thereby squashing debate. There is certainly strength in diversity of ideas and experiences...it serves to make the whole organization stronger. Certainly, nepotism of any sort, if that's what is happening, is not a healthy habit and it should be nipped in the bud before it becomes endemic.

- Matthew J. Arciuolo, C. Ped.

Off-loading the Diabetic Foot for Ulcer Prevention and Healing

Peter R. Cavanagh, PhD, DSc ^* and Sicco A. Bus, PhD 

Abstract

Retrospective and prospective studies have shown that elevatedplantar pressure is a causative factor in the development ofmany plantar ulcers in diabetic patients and that ulcerationis often a precursor of lower-extremity amputation. Herein,we review the evidence that relieving areas of elevated plantarpressure (off-loading) can prevent and heal plantar ulceration.There is no consensus in the literature concerning the roleof off-loading through footwear in the primary or secondaryprevention of ulcers. This is likely due to the diversity ofintervention and control conditions tested, the lack of informationabout off-loading efficacy of the footwear used, and the absenceof a target pressure threshold for off-loading. Uncomplicatedplantar ulcers should heal in 6 to 8 weeks with adequate off-loading. Full Text

Source: japmaonline.org

Professor Hopes Research Gives People a Foot Up on Diabetes

If you have diabetes and a sore on your foot that just won't heal, then Stacey Reading wants to talk to you.  Actually, what the professor of kinesiology at the University of New Brunswick really wants to do is dunk your injured foot in oxygenated water to see if it will get better.

"This is something that no one has ever really ever looked at," he said in a recent interview. "This is pretty new stuff in terms of what we are doing."

Reading said last year he was approached by a Fredericton company called InVentures Technologies Inc., which produces the equipment that puts the extra oxygen into water. Full Text

Source: New Brunswick Business Journal

SPORTS AND FITNESS

U.K. Certified Pedorthistis the Boot Doctor at the British Ski & Board Show

If you're planning a visit to the British Ski and Board Show taking place at Birmingham NEC from 29th - 31st October, make sure you book an appointment to see 'The Boot Doctor'. Whilst you may have all the gear prepared to head off to the slopes this winter ensure you visit the Show's Talk Theatre to learn the importance of selecting the right footwear to accompany your skis. According to a report by French Doctors, ill-fitting ski boots are the cause of up to half of all knee injuries and advises skiers to have their boots checked by a professional before heading out on the piste.

With over 18 years experience of fitting all types of footwear 'Boot Doctor' Colin Martin is a fully qualified Certified Pedorthist (C.Ped) and set up Solutions4feet in Bicester (Oxfordshire) in 2005. Specialising in fitting the correct footwear for a variety of leisure and sport activities Colin strives to make sore feet a thing of the past by offering a bespoke service and foot care programme. Full Text

Source: ifyouski.com

U.K. Certified Pedorthistis the Boot Doctor at the British Ski & Board Show

If you're planning a visit to the British Ski and Board Show taking place at Birmingham NEC from 29th - 31st October, make sure you book an appointment to see 'The Boot Doctor'. Whilst you may have all the gear prepared to head off to the slopes this winter ensure you visit the Show's Talk Theatre to learn the importance of selecting the right footwear to accompany your skis. According to a report by French Doctors, ill-fitting ski boots are the cause of up to half of all knee injuries and advises skiers to have their boots checked by a professional before heading out on the piste.

With over 18 years experience of fitting all types of footwear 'Boot Doctor' Colin Martin is a fully qualified Certified Pedorthist (C.Ped) and set up Solutions4feet in Bicester (Oxfordshire) in 2005. Specialising in fitting the correct footwear for a variety of leisure and sport activities Colin strives to make sore feet a thing of the past by offering a bespoke service and foot care programme. Full Text

Source: ifyouski.com

Seeking to Hire: Since our company's founding in 1923, Yale Surgical Company has been dedicated to meeting the Orthotic, Prosthetic and Pedorthic needs of Connecticut.  We are beginning a new family generation of practitioners and are eager to meet the continuing need in our area. We currently have multiple opportunities for C. Ped., CO, CP, CPO and Orthotic/Prosthetic Techs in our New Haven office. We would love to speak with you to discuss your goals and future plans. Please feel free to look at our website, http://www.yalesurgical.com/ and email your resume to info@yalesurgical.com at your earliest convenience. Comp. salary, 401k etc. - Edward N. Kaufman Ongoing

Seeking Employment: Certified Pedorthist looking for employment in the Central Indiana area.  Possess 25 years experience in Orthopaedic and industrial footwear and customer service.  Trained in Orthopaedic modifications and shoe repair, I own vacuum press and oven for custom lab work.  Clinical experience working in Indiana's largest wound care center.  I'm looking for a position with Pedorthic, Lab, or O & P business servicing patients and clients.  Please contact: pltrwart@sbcglobal.net   9/30

Seeking to Hire: Interested in hiring a C. Ped. with experience in fitting the diabetic patient.  Preferably, the individual should be residing within ½ hr. from our facility, which will be based in Lakewood, NJ. 08701 please contact Judah Rosenberg at: 917-309-1341 or pedicare2@gmail.com  9/22

Female Certified Pedorthist looking to share hotel expenses with another female C. Ped. for the 2010 North American Pedorthic Congress in Orlando this November. Also looking to share cost of getting to/from the airport. Considering staying at a different hotel other than the Hilton Walt Disney World in order to cut down on costs. Please email mydancingfeet@hotmail.com 9/1

Seeking To Hire, New Jersey: AmPed Foot Health. Experienced Certified Pedorthist wanted for shoe/orthotic fitting. Off-the-shelf and custom. We specialize in clinical/institutional environments throughout mostly Northern and Western Counties. Presently expanding further south into Central areas. Perfect position for a caring, personable, self-starting individual. Flexible hours with good growth potential for the right person. Salary commensurate with experience. Please forward resume to smandel@ampedfoot.com. 8/25

Inventory For Sale: We have closed our retail comfort shoe store and have a large amount of comfort shoes to sell.   SAS, Brooks, Drew, Durea, P. W. Minor for less than cost.   Contact me:  Lee A. Hunter 417 496-0808 for a list of the inventory. 7/28

Seeking Employment: Certified Pedorthist with varied pedorthic background seeking position in Colorado. Prefer footwear/orthotics/sports environment or clinical setting that has its own billing staff and insurance gurus. Contact: certpedorthist@yahoo.com 7/21

Classifieds will run for 90 days unless we are informed that the position has been filled.  Thank you!

Editor: Faye Rapoport DesPres, M.S., M.F.A.

Design/Layout: Aetrex Marketing Department

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