Exploring Another View On The DPM/MD Debate

   The debate that continues about the DPM/MD or DPM/DO dual degree is understandable, as demonstrated by Duane Dumm, DPM (see pg. 14, “Dual Degrees May Not Benefit DPMs,” March issue). Change is difficult. Change is suspect. Change is resisted. However, in podiatric medicine, change is a function of rapid growth with dimensions of practice that many take for granted and perhaps others do not fully realize.    First, dual degrees are not simply programs designed to benefit the DPM. While there certainly is a benefit to the podiatric physician, the ultimate benefit should be to the patient who requires our professional services. Will dually degreed podiatrists hold themselves out to be DPMs, MDs (or DOs)? Hopefully, those who select this path will use both degrees and even both licenses.    For several decades, dually degreed oral surgeons with DDS and MD degrees have in the overwhelming number of instances practiced as oral and maxillofacial surgeons, providing added value to their patients. Do they list themselves in classified telephone directories under the heading of MD and the heading of DDS? Certainly, they often do both but they have earned it and are not doing anything morally or ethically repugnant nor would they be doing anything to cause damage to their profession.    In fact, the opposite is true. The oral maxillofacial surgeon DDS/MD degree has not hurt the profession of dentistry or any of its schools.    Not only am I currently involved in initiating the DPM/DO degree program in the United States, I have also been invited by the Chair of the Oral and Maxillofacial Surgery Department and the Dean of our College of Dental Medicine to help them develop a DMD/DO program at our medical school.

Keep The Debate In Perspective

   As a podiatric physician for many years, I have seen scathing responses by well-meaning, prominent and caring members of our profession about many changes that have occurred. The issues have ranged from the podiatric medical schools and the residency “movement” to the establishment of board certification and the expansion of practice rights. The concept of creating a two-year residency was revolutionary, let alone a three-year program. The requirement to complete residency training was fought and the decision to establish board certification in podiatric surgery was at least as traumatic.    As the DPM/MD or DPM/DO program is beginning to become a reality and a forum for heated argument, I mainly get visions of déjà vu. Indeed, these battlegrounds come and go, and the profession becomes far better as the resulting changes are implemented. The same will be true with those in the profession who choose to obtain dual degrees and licenses as DPMs and/or as MDs or DOs. Our profession will be better off because of these changes. Our patients will not be confused. They will be better served. Lastly, in response to Dr. Dumm’s question: will new graduates with a MD or DO “limit themselves to treating nails and calluses?” I don’t think so but I hope those graduates who “only” have the DPM degree don’t do so either. - Leonard A. Levy, DPM, MPH Associate Dean For Education, Planning And Research Professor of Family Medicine and Public Health Nova Southeastern University College of Osteopathic Medicine levyleon@nsu.nova.edu

Why I Don’t Find It Necessary To Excise Morton’s Neuroma

   To excise or not to excise? In my office, there really is no question. I have not found it necessary to excise Morton’s neuroma in the last 40 years. I base my statements on my 55 years of experience with thousands of patients. Personally speaking, I have also had many years with no post-op problems after undergoing surgery on both of my feet to relieve the pain and burning associated with Morton’s neuroma.    I still have a Morton’s neuroma in each foot but following the removal of the medial side of each fourth metatarsal head, I still have no Morton’s neuroma symptoms.    Before one considers any surgical options, it is wise to follow a course of conservative therapy. I use a combination of physiotherapy, strapping and the 4% dehydrated alcohol/Marcaine injection.    I want to thank Gary Dockery, DPM, for reintroducing this combination of drugs in recent years. (See “Is Injection Therapy The Best Solution For Foot Neuromas?” in the January 2002 issue and “When Injection Therapy Can Help Relieve Painful Lesions” in the June 2002 issue.) I also want to compliment him for giving full credit to the late, legendary Marvin Steinberg, DPM, who taught us about this injection many years ago.    If a course of conservative care does not resolve the pain and burning associated with Morton’s neuroma and surgery is indicated, I proceed to use a combination of non-endoscopic neuroma decompression and removal of the medial side of the fourth metatarsal head. One can perform both procedures through the same incision but I bill the insurance company for only one procedure.    As far as the anesthetic goes, I use 50 ml of 1% lidocaine without epinephrine, pre-mixed with 20 mg of dexamethasone phosphate. I use this combination for all foot surgeries including bone surgery. This combination eliminates post-op pain to the point where it is rarely necessary to prescribe any post-op medication for pain.    For those who prefer only the neuroma decompression, I perform the non-endoscopic neuroma decompression, a procedure that I routinely perform in less than five minutes (after anesthesia) using only a #67 mini-blade. Approximately 3 ml of the combined anesthetic is infiltrated proximal to the neuroma. The length of the incision is a personal choice. I prefer a 1/8-inch skin incision about the mid-fourth metatarsal head on the medial side. Since every first-year podiatry student already knows the intermetatarsal ligament is located plantarly (it cannot be anywhere else), it is not necessary to search for it.    After inserting the mini-blade through the skin, push it plantarly using a pendulum motion. Keep the blade close to the fourth metatarsal head. This reduces the chance of severing any other soft tissue. It should only take several seconds to reach and sever the ligament. As soon as you cut the ligament, you will find that the blade will meet no resistance with the pendulum motion. Cover the surgical wound with a small bandage. This allows immediate post-op ambulation and driving.

What About Eliminating The Medial Side Of The Fourth Metatarsal Head?

   We all know that pressure against the metatarsal heads (i.e., tight shoes) squeezes the third and fourth metatarsal heads together, causing pain and burning in the presence of Morton’s neuroma. By eliminating the medial side of the fourth metatarsal head, the neuroma is no longer entrapped between the bony projections of the two adjacent metatarsal heads.    Removing the bony projection without removing the neuroma eliminates all those post-op problems clinicians encounter if they only excise the neuroma.    Accordingly, I perform neuroma decompression and remove the bony projection of the medial side of the fourth metatarsal head. (This bony projection is longer than the lateral side of the third metatarsal head.)    Through the original 1/8-inch incision, I again use the #67 mini-blade to open enough of the distal end of the capsule to insert the small end of a sharp #12 bell rasp. I proceed to file down the bony projection until it is smooth to the level of the metatarsal shaft.    I use the remainder of the anesthetic combination in the 5 cc syringe to flush out the bone granules. This also leaves a small amount of steroid within the capsule. This subsequently eliminates enough of the pain so post-op pain medication is rarely necessary. Then one would cover the post-op wound with a small bandage. This allows immediate post-op ambulation and driving.    These are almost band-aid surgeries that I routinely perform in my office.

Final Notes

   Another issue to consider is whether Morton’s neuroma can be a cause of sciatic pain. The last two branches of the sciatic nerve end up between the third and fourth metatarsal heads, and into the neuroma.    A simple diagnostic test is blocking off the neuroma with 3 ml of your favorite local anesthetic. If the sciatic pain dissipates (sometimes before the patient even leaves the office), it logically follows that the Morton’s neuroma is sending nerve impulses up the leg into the sciatic nerve, irritating it and causing pain.    In my practice, the injections work about 80 percent of the time. For those few who are not helped with the injections, I will refer them to an orthopedic surgeon or a chiropractor. Once the patient is convinced that Morton’s neuroma is the cause of his or her sciatic pain and if he or she has failed conservative therapy, I will perform the aforementioned surgeries. - Albert R. Brown, DPM Coconut Creek, Fla.

Emphasizing Direct Treatment Of Veins In Venous Ulcer Cases

   In a recent continuing education article, “Treating Venous Stasis Ulcers In The Lower Extremity” (see page 69, October 2004 issue), Mark Beylin, DPM, addressed several very important issues. In my opinion, there is another area that could have been stressed and that is the direct treatment of the veins themselves, and not just the ulcer.    While compression and elevation are certainly cornerstones of treatment, they also extend the long-term disability that may be circumvented by either Subfascial Endoscopic Perforator Surgery (SEPS) or Endo Venous Laser Treatment (EVLT), or both.    A qualified ultrasound technologist who works with a vascular surgeon experienced in venous disease can determine if there is reflux from the deep to superficial system in the groin (at the saphenofemoral junction) or in the leg from perforator incompetence. Each of these conditions can be treated with the aforementioned minimally invasive procedures, which can be very effective in limiting the extent and duration of disability in large numbers of patients. - J. Pecoraro, MD, FACS jpp@floridasurgeon.com