What About Cryosurgery For Interdigital Neuritis?

   Babak Baravarian, DPM, first of all, I want to say I always find your articles very educational and informative. As a CryoStar cryoanalgesic certified podiatrist with over 100 clinical cases under my wings, I wanted to add my spin on interdigital neuritis to your perspective (see “How To Diagnose And Treat Interdigital Neuritis,” page 67, January issue).    The use of cyroablation for treatment of Morton’s neuromas received FDA approval in June of 2003. With my colleague, Lawrence Fallat, DPM, and the other 19 CryoStar surgeons, we have treated well over 1,000 neuromas as a collective group. We have close to a 90 percent success rate with one seven-minute in-office treatment.    The advantage of our technique is that it causes no postoperative neuritis or neuralgia. By freezing with nitrous oxide at these temperatures, we are causing a conduction block, similiar to what a local anesthetic does to the nerve but with a greater period of relief. The extreme cold will destroy the endoneurium. However, the epineurium and perineurium remain intact. There is little to no post-op discomfort and patients can be totally asymptomatic within five days.    Granted, there is a place for all forms of treatment. However, in the literature I have reviewed and after speaking with surgeons who are performing the KobyGard and endoscopic decompression of intermetatarsal neuroma (EDIN) procedures, they do not get the level of success that we get with cryosurgery. I have performed many procedures on patients who have had failed intermetatarsal ligament releases but I feel these releases only treat a symptom and not the true root of the problem. Certainly, many of the large neuromas we treat do not seem to respond to these releases. Steroid injections are a temporary fix.    I am not stating that cryosurgery is the only way to treat the problems but with the numbers and results we are getting, we certainly can make a good case for our technique. — Steven H. Goldstein, DPM, DABPS stevefootdr1@cs.com

Dual Degrees May Not Benefit DPMs

   I would like to thank Podiatry Today for offering a dissenting view to the push for the dual degree. (See “Should We Add ‘MD’ To Our Credentials?,” page 74, September 2004 and “Revisiting The DPM/MD Debate,” page 16, November 2004.) What happens when these graduates (with dual degrees) begin to go into the communities and advertise themselves as the best trained physicians for the foot and ankle? How do the existing DPMs compete with that? Some will get by on their fine reputations but others will find themselves sunk.    Let’s face it. Patients are often drawn to the doc who promises the most even if they cannot deliver. How will these new graduates present themselves? Will they present themselves as podiatrists or MDs/DOs? Most likely, they will flip-flop to whatever will serve them best at the time. In other words, for a listing in the phone book, they may be podiatrists. To get on a board or a certain committee, they may present themselves as DOs. This will only confuse the public and a medical profession who are just now understanding what we do.    How long will it be before the insurance plans exclude DPMs and only allow this new breed (who will not be calling themselves DPMs) to treat their members? I have been out of the Ohio College of Podiatric Medicine (OCPM) for 11 years and still have student loans. How am I to go back to school to increase my degree? Who will the APMA lobby for if it even exists in 10 to 15 years? I think it is a breech of trust that the schools will be saying to the public, “Sure, we graduated DPMs but this newly degreed doctor is better.”    Lastly, why does anyone believe these new graduates with an MD or DO are going to limit themselves to treating nails and calluses? When they discover that there are better paying and easier procedure codes, they will go there. — Duane Dumm, DPM podtoo@aol.com

Additional Observations On Leg Length Discrepancy

   I was thumbing through some old copies of Podiatry Today when I came across an excellent article entitled, “How to Evaluate For Leg Length Discrepancy” by David Levine DPM, CPed (see page 68, June 2004). I do not see much in the literature about this condition and I think its evaluation is a lost diagnostic opportunity.    I practiced for 38 years and dispensed more than 10,000 pairs of inlays/orthotics during that time. I rarely dispensed a device without some accommodation for leg length discrepancy (LLD). I would like to add a few observations regarding this condition from my experience.    • Body symmetry probably does not exist.    • From a treatment standpoint, it doesn’t matter whether the LLD is congenital, developmental, acquired, structural or functional. Patients, especially those with unilateral pathomechanical conditions, will have a LLD, and the symptoms will almost always be on the short side due to increased trauma.    • The most reliable way to diagnose LLD is with a weightbearing AP ankle X-ray. Draw a horizontal line connecting the medial malleoli to determine which is shorter and the relative degree. Calculating the exact amount of the shortage is probably not possible (or even necessary). Another excellent diagnostic tool is for patients to stand in front of a full-length mirror and observe the asymmetry between the knee, hips and breasts (men and women). Their reported findings will be useful.    • Whatever accommodations one wishes to use, they should be made incrementally.    A 1/2-in. to 3/4-in. LLD may only require a 1/8-inch heel lift at a time to make a difference. When the patient has accommodated to the change, an additional lift can be added to the patient’s tolerance. The vast majority of LLD accommodations I used also incorporated an outside heel wedge, because when the patient falls off the long side, he or she lands on the outside of the foot on the short side.    While biomechanical technology has become more sophisticated and more DPMs rely on angles, numbers and printouts, observation and cognitive thinking have played less of a role in diagnosis and treatment. I was glad to see Dr. Levine’s article and hope I may have contributed something useful with these observations. — Kove J. Schwartz DPM, JD, MPA

Why I Prefer Custom Orthotics

   In regard to the recent News And Trends article, “Study: Custom Orthotics Not Necessarily Better Than Prefab Devices” (see page 6, February issue), I am a 59-year-old male and I recently had plantar fasciitis problems in my left foot, which has an extremely high arch.    I tried at least five prefabricated orthotics to no avail. Then I bit the bullet and had a custom orthotic made. Bingo. There was no pain in about two weeks. When I tried to go back to a prefabricated model, the agony returned in short order. The custom device cured it again.    No study will ever convince me that, for all feet, that generic orthotics are as good as custom orthotics.    For those who have an arch height within the realm of prefabricated orthotics, a trial of these devices is very reasonable. However, if one’s arch is higher than that, one can save a lot of time and expense by simply getting a custom orthotic. — John Bell, MD

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