Podiatrist - Sacramento
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Sacramento, CA 95819
By contactus@podiatryclinician.com
June 05, 2013
Category: painful feet
Tags: Summer  

Flip-Flops May Put You on Path to Foot Trouble




FRIDAY, May 31 (HealthDay News) — From poolside to an evening out on the town, for many people, flip-flops have become a summer staple. This popular style of footwear, however, may not be the best choice for every situation, an expert warns.

“While flip-flops are perfectly fine — and far better than going barefoot — in a number of settings, they do have some drawbacks,” said Dr. Christina Sigur, a podiatrist and instructor in orthopedics at Wake Forest Baptist Medical Center.

“They really don’t offer too much support or protection. Wearing them too often or for certain intensive activities can lead to a variety of foot problems,” she explained in a Wake Forest news release.

The American Podiatric Medical Association offers these flip-flop safety tips:

  • Look for leather. Flip-flops made of high-quality leather are less likely to cause blisters and other types of irritation.
  • Sturdy is better. Avoid flimsy flip-flops that you can bend in half. Instead, opt for a pair that bends at the ball of the foot. This is particularly important when you are at the beach, in hotel rooms or locker room areas and walking around a public pool.
  • Consider fit. Your foot should not hang off the edge of the flip-flop.
  • Watch for signs of wear. It’s not a good idea to wear the same pair of flip-flops year after year. Once they show significant signs of wear, it’s time to get a new pair.
  • Pay attention to your feet. Do not ignore irritation between toes, which can lead to blisters and possible infections.

The American Podiatric Medical Association noted that flip-flops are not appropriate footwear for all situations. The group advised that people not wear flip-flops when walking long distances, doing yard work or playing sports because these shoes do not offer much shock absorption or arch support, and they do not fully protect the feet.

“I specialize in foot and ankle medicine and surgery, and prevention is a big part of my practice,” Sigur noted. “When it comes to flip-flops, all it really takes is a little common sense to avoid injuries.”

More information

The American Podiatric Medical Association provides more flip-flop safety tips.

By contactus@podiatryclinician.com
May 31, 2013
Category: Toes
Tags: Toe Deformity  




Crossover 2nd toe is similar in appearance to a hammer toe, however apart from appearance, this is a different disorder which causes distinct and seprarate impairment.  The natural progression of this deformity arises as a consequence of 2nd metatarsal overload syndrome, a cascade of adverse events causing musculoligamentous contracture and derangements resulting in the abnormality of the bone and joint of the second toe.  This deformity is typically seen in conjuction with a bunion of the great toe joint with an angular deformity resulting in the great toe crowding and bucking against the 2nd toe. 

The crossover 2nd toe occurs in people whose functional instability of foot motion causes stressors during weight bearing activities which create an overloading of the second metatarsal .  Factors such as tight calf muscle (equinus), hypermobile foot type with arch collapse and bunion contribute to acceleration of the crossover 2nd toe deformity.  Over time the stress in this location leads to weakening of the ligaments and capsule of this joint. Although this may begin as an isolated pain, over time the structures stretch out or rupture and the deformity occurs.

The crossover second toe deformity may be one of the most challenging surgical disorders foot and ankle surgeons face. The condition is most often associated with a pronounced hallux valgus deformity that one must address surgically in order to achieve a satisfactory and lasting result.

The plantar plate is the major stabilizing structure of the joint due to its central location and multiple important attachments.

New instrumentation has greatly faciliated the repair of this deformity by allowing a mechanism and means to reattach the ruptured plantar plate of the 2nd toe.  The CPR Micro SutureLassos and Mini Scorpion DX. The surgical treatment that reconstructs the anatomic structure that leads to the instability of the 2nd MTP joint. A plantar plate repair and lateral soft tissue reefing can restore the normal alignment of the joint with anatomic repair.






By contactus@podiatryclinician.com
February 11, 2013
Category: Health Policy


Reposted from Dr. Kevin Campbell MD


In the past, learning about a good doctor or a pleasant hospital experience was a “word of mouth” phenomenon.  Today, more and more patients are going online for information about potential healthcare providers and hospital systems.  But exactly how accurate is the information they are accessing?  Recently, multiple surveys and research investigations have been published about the validity of online physician review sites.  Like most things that we find on the internet, the best advice is to take what you see there “with a grain of salt”.

A recent survey performed by the Pew Research Center asked participants a simple question.  “What percentage of adult internet users have consulted or posted online health reviews?”  The results are quite startling.  The minority of users actually post--but a fair number of users read and consult these reviews.


Source:  Pew Research Center “Health Online 2013”

So, as consumers of healthcare, how in the world do we interpret this data.  The fact that only 3% of the folks surveyed actually posted reviews suggests that the reviews are somehow biased--either good or bad.  This can certainly lead to misleading comments and ratings and can drastically change how a provider is perceived.  We must remember that these MD ratings sites are unregulated and not very well controlled or policed.  Typically, in any customer service industry, we find that most comments come from dissatisfied customers--it is rare in corporate America that someone takes the time to leave a positive comment.  There have been many published studies in the literature have shown that negative events are much more likely to elicit comments.

An article published in the New York Times in March 2012, discusses the neuropsychiatric basis for this very fact.  In the article, Stanford researcher Dr Clifford Nass states that the brain handles positive and negative events differently and in these events are even processed in separate locations within the cortex.  His research has demonstrated that we tend to process negative experiences more thoroughly and tend to ruminate about negative more than positive--in other words it takes many many positive experiences to overcome one negative interaction.  A recent study in the Journal of Urology evaluated the ratings of common sites such as Vitals.com, Healthgrades.com and RateMDs.com and found that from a random sample of 500 Urologists whose ratings were examined, the average number of evaluations for each was 2.4 ratings.  Many of the reviews focused more on the office experience (decor, wait times, etc) rather than the interaction with the physician or the providers knowledge or ability.  Obviously with very few respondents the results can be significantly skewed by either a remarkably high or a remarkably low rating.  The results suggest that physician rating sites are probably not the most effective way to evaluate your next  potential healthcare provider

What are some possible sources of bias in MD ratings?  The internet allows for anonymity and promotes the ability to say things that we normally may not say in a face to face interaction.  Disgruntled employees, angry family members or patients frustrated by their disease may provide unwarranted negative ratings to healthcare providers.  Conversely, family members and friends may also provide unwarranted high praise.  Altogether, these types of bias limits the utility of physician ratings sites.  Other options for choosing a provider include social media sites such as twitter.  There are disease specific tweet chats that promote interaction among patients.  Patients in the chat often recommend certain therapies, physicians and hospital systems.  These groups tend to be very well informed and the information is fairly reliable.  Ultimately, as an article on the NPR website last week suggests--we  may just have to go back to the prehistoric pre-digital era when it comes to rating and choosing physicians--we might just have to talk to one another!

By contactus@podiatryclinician.com
October 22, 2012
Category: Injuries
Tags: Women  

            Wearing high heels is your choice, but you should at least be aware of the problems related to high heals. Women have four times as many foot problems as men.    Researcher Danielle Barkema Iowa State University (ISU) selected three different heel heights – flat, two inches, and 3.5 inches – and had each of the 15 women in her study complete walking trials. She measured the forces acting about the knee joint and the heelstrike-induced shock wave that travels up the body when walking in heels. Using sensors, accelerometers and lab equipment such as a force platform and markers/cameras, she was able to capture motion and force data and translate them into results that could change the way millions of women select their footwear.  The evidence was presented at the 2010 meeting of The American Society of Biomechanics (ASB) which was founded in 1977 to encourage and foster the exchange of information and ideas among biomechanists working in different disciplines and fields of application 

            While previous studies have examined the effect of high heels on joints, the ISU researchers found that heel height changes walking characteristics such as slower speeds and shorter stride lengths. And as the heels got higher, they also saw an increase in the compression on the inside – or medial side – of the knee. Prolonged wearing and walking in heels could, over time, contribute to joint degeneration and knee osteoarthritis 

            Wearing high heels is a major reason for this. Physical problems associated with high heels include foot pain, foot deformities, a change in back posture, knee osteoarthritis and balance impairment.  High heels can contribute to the development of a variety of conditions like arthritis, chronic knee pain, sprained ankles and back problems. High heels can also result in a variety of foot problems. High heels could be the cause of knee osteoarthritis, a painful, degenerative joint disease. The knee osteoarthritis is characterized by the breakdown of the cartilage surrounding the knee.

           You could have ankle sprains and breaks from rolling over on high-heeled shoes. If you wear high heels you probably had this kind of problem. You should also know that high heels are pumps with heels of more than two inches 

By contactus@podiatryclinician.com
October 15, 2012
Category: Health Policy
Tags: Health System  

The unpredictable risk and benefit of Medicare vouchers  Reposted from the American College of Physicians blog post Bob Doherty

Monday, August 27, 2012 

Trying to figure out whether Medicare vouchers are a good idea for patients and their physicians?  Then consider these two basic questions:

  1.  How much will the federal government contribute?
  2.  Who is at risk for health care cost increases?

How much will the government contribute?  The traditional Medicare program has no set limit on how much the federal government will contribute to a beneficiary’s health care, although there are limits on how much it will pay doctors and hospitals.  That’s what makes it an open-ended entitlement.  Medicare vouchers (or premium support, if you prefer) place an annual limit on how much the federal government will contribute, and anything above that comes out of the beneficiary’s own pocket.  As such, Medicare would no longer be an open-ended entitlement, but a defined contribution program.

One can imagine a voucher that would be so generous that beneficiaries could buy even more coverage than they have today under the traditional program.  But that would defeat the purpose of vouchers, which is to drive down costs.  So by necessity, the federal voucher contribution has to start out by being less per person than the government is now spending on traditional Medicare, or it won’t save money, right? 

And no matter where the initial dollar amount is initially set—let’s assume that it would start out being pretty generous, good enough to buy a health plan that offers benefits comparable to traditional Medicare--the government would have to decide how much it would be allowed to go up each year:  enough to keep pace with rising health care costs or less than that?  If the federal contribution doesn’t keep up with average costs of the benefits covered by Medicare, beneficiaries would pay more, but the government saves more; if it keeps pace with average costs, the government saves less but beneficiaries pay less. 

Voucher advocates say that the cost-savings will principally come from competition among competing health plans, and if so, seniors wouldn’t necessarily have to pay much more than they do today and the government would still save money.   Beneficiaries will have an incentive to choose a health plan that offers coverage at a premium that is not much more than the voucher amount.  Insurers will have an incentive to keep costs close to the voucher amount or risk being priced out of the market. 

The theory sounds good—but let’s look at who is really at risk for keeping costs down under a Medicare voucher system (hint: it isn’t the government).

Who is at risk?   Competition between health plans and traditional Medicare will only be successful in driving down costs if the competing health plans can use their market power to change the behavior of patients, physicians and hospital.    That’s because health plans (except for ones attached to physician group practices and hospitals) don’t really deliver care, they pay for it, through contracts with physicians and hospitals.

In a voucher system, competing health plans will try to drive down those costs by leaning on patients and “providers” to lower costs.  They might pay clinicians and hospitals less, hire less expensive mid-level providers, restrict patients to an approved network of providers, pay their network “providers” based on performance (lower costs, and one hopes, also better outcomes) rather than volume, deny claims for services, demand lower rates from drug companies and device manufacturers, require that Medicare patients enrolled in their plans pay more out-of-pocket, and place limits on benefits (to the extent that they are allowed to by the government). 

The better and more innovative plans might try to organize care better to achieve improved outcomes more efficiently, through models like Patient-Centered Medical Homes. 

So to a great extent, under a voucher system, it’s the physicians and hospitals who will be at risk for cost increases, because to be successful in keeping their premium costs competitive, the insurers would have to get the “providers” and “suppliers” of care to charge less and deliver services more efficiently

Health plans that are integrated with physician group practices and hospitals would likely have a competitive advantage under a voucher system because they can “organize” their providers more effectively than traditional insurers that contract with individual physicians and hospitals on an a la carte basis.   Vouchers, then, might accelerate the trend to hospital-physician-insurer consolidation, at the expense of physicians in independent practice.

But patients enrolled in Medicare would be the ones at the greatest financial risk: either because they would get fewer benefits and have to pay more out of pocket for the less costly plans that the voucher amount would (mostly) cover, or because the federal contribution falls short of the cost of the premiums charged by the competing plans, with the difference made up by them. A new study by the liberal-leaning Center for American Progress Action Fund, based on the Congressional Budget Office’s analysis of the most recent version of Rep. Ryan’s Medicare premium support proposal, concluded that if competition doesn’t lower costs enough, the voucher contribution would not keep pace with rising costs—and the result would to vastly increase beneficiaries' average health care bills over their retirement years:  

--For seniors reaching age 65 in 2023 by $32,900
--For seniors reaching age 66 in 2030 by $73,600
--For seniors reaching age 67 in 2040 by $139,100
--For seniors reaching age 67 in 2050 by $225,200

I am sure that voucher advocates will take issue with those estimates, because the Center assumes that competition between health plans—and, more to the point, health plans’ ability to drive savings out of the “providers” and suppliers of health care-- won’t be effective in slowing cost increases, so beneficiaries will be left holding the bag between the capped federal contribution and the average premiums.    

Neither voucher advocates nor voucher critics really know for sure, since this is uncharted territory—there is no actual real-life experience with instituting a voucher system on a large scale basis for people who, by definition, are older and need more health care.  Competition might be enough, but if it isn’t, the cost-shift to seniors would put affordable health care out of reach for many, if not most of them.

Given the uncertain benefits and risks of vouchers, wouldn’t it make more sense to first pilot test a premium support system, as the American College of Physicians has recommended in a recent position paper before adopting it as national policy?  This is how ACP puts it:

 “It is vitally important that a premium support model be tested to determine possible adverse effects or unintended consequences. Particular attention should be given to such issues as enrollee and provider reaction, plan participation, market effects, premium levels, and barriers to care. If done properly, a defined benefit voucher program may encourage beneficiaries to select coordinated care plans that may promote preventive care, wellness, and better cooperation among physicians and other health providers. However, caution should be exercised prior to implementing such a significant change in Medicare financing that will affect millions of the nation’s elderly and most vulnerable citizens.”

A pilot-test, in other words, would be the sensible, even conservative approach to resolving the voucher controversy, because it would allow us to learn from real-life experience how premium support might be designed and work in practice, and what its effects are on patients and physicians, rather than embracing or rejecting vouchers based on unproven ideology, beliefs, conjecture and assumptions.

Today’s questions: Who do you thinks bears the greatest risk under a Medicare voucher system?  Do you agree that it should be pilot-tested first before a decision is made on its adoption?

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Podiatrist - Sacramento, Bruce D. Gorlick, D.P.M., 3939 J St., Sacramento CA, 95819 916-739-6666