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Tuesday, November 29, 2011

Socks for Cold Feet: Infracare To the Rescue

Please check out this product for cold feet. Anyone with personal comments please be sure to comment. Add this to my previous recommendation of ToastieToes sold at REI and Amazon. Hope this helps you.go.cfm.jpg

Monday, November 21, 2011

More Advice on Sesamoid Injuries: Email Style

Again I must apologize to Tammy and all who have been waiting for me to respond to their email.s. Thank you Tammy for re-emailing me to get the ball rolling again.

Hi Dr. Blake,

I sent you an email with lots of questions about a month or so ago.
Dr Blake's comment: Sorry!!

 This is the link if you need:

 I have a couple other questions for you. I saw a podiatrist and he suggested removing the fibular sesamoid bone rather than trying the bone graph that the orthopedic doctor suggested. So I am waiting to see him again to schedule surgery.
Dr Blake's comment: I just have not seen bone grafting on this injury, plus bone grafting causes unpredictable amounts of bone growth (perhaps into the wrong areas).

 My question is about the surgery to remove the bone, what are the statistics for the surgery as far as positive and negative outcomes?
Dr Blake's comment: I do not know statistics, but these surgeries do very well. If I was to have surgery, I would remove it and then protect it for the rest of my life (sounds harder than it is). My patients do well, but Keely due to some pain did not return to running, and I am not sure why.

Also how long does it take to recover from the surgery mostly in order to return to work and of course to the dojo too. I am still working to find a comfortable arrangement of the taping and the off setting the foot with the pads, that is a work in progress.
Dr Blake's comment: So, it is normally 4 days on crutches, then another 10 days to 17 days until the sutures can be removed. Once the sutures are removed, then soaking, swimming, sweating is allowed. Physical Therapy is started at 2 weeks and runs initially for 10 weeks twice a week. Some time over the first year there may be another bout of 10 physical therapy visits for some reason. The return to work is based on need of feet. I sit on my butt most of the time, so I would be back at work in 4 days. Most of my patients are smarter than me and take 2 weeks off. Your work has to be tolerant of time off for PT, but many places office after, before, or Saturday appointments to get those 2 in per week.

While looking at new posts you have made I found this link:

 and I have a question about the pictures. On the fourth picture where you are showing the placement of the felt, the boot you are showing is much shorter up the leg than I have been able to find. It looks like it comes up just above the ankle. If this is so, where can I find one? I have just about worn out my second cam walker and I have been looking for one that is this low.
Dr Blake's comment: Here is the link:
You want it to grab your ankle so there is no motion there.

My final question is about orthotics, the doctor suggested purchasing orthotics with a morton's support which is supposed to keep the big toe side of the foot straight. After I have surgery to remove the bone, will that be necessary or will the orthotics need something different?
Dr Blake's Comment: Normally, after surgery, a reverse Morton's, also called a dancer's pad, is used to off-weight the area.

 If I am going to buy the orthotics which are not covered by my insurance, I would like them to be good for a while until I wear them out. Or is this something that I talk to the person when they fit them?
Dr Blake's comment: When you talk to the orthotic guy/gal, make sure they are willing to experiment between forefoot supports (Morton or Reverse Morton corrections) and pronation control (some guarentee that your weight at pushoff will be more in the center of your foot for awhile).

I have been using the bone stimulator for about 3 months over night, wearing the cam boot daily with taping and the padding to off set the foot placement.

 I am not consistent on taking the vitamin D and calcium or the soaking which I am working on since I know it will help.
Dr Blake's comment: You must do these things or Santa will leave coal. Please know how vitally important it may be to your health.

 This weekend marks 8 months since the injury and I feel my foot is in the same situation it was 5 or 6 months ago. Reading the information from your blog helps to see what you suggest and how others are dealing with this injury. I appreciate your wisdom and your willingness to share that information with everyone. Thank you again for your help and have a wonderful Thanksgiving!

Tammy, I hope this helps and I am soo soo sorry for the delay. Rich

Sunday, November 20, 2011

Lifts for Short Leg: Email Advice

This email was received several monthes ago. I apologize for the delay in responding.

Dr Blakes,
I've read through a lot of your information on foot lifts. Having researched this kind of information for a few years, I can tell you have a great knowledge on the subject.

Before I ask my questions I will give you a quick background on my situation.

I'm an avid runner and have been running competitively for 6 years. About 3-4 years ago I've noticed a glitch in my gait. To figure it out I've seen chriopracters, podiatrists and PTs. First it was thought as just a strength imbalance, particular in my G- Medius. Then it was diagnoised as a functional LLD. Next it was determined it was 11-12 mm ALLD by a plevic x-ray femur head height comparison. Lastly, I went on my own to get a full body x-ray. This confirmed that I have ALLD and that it's that my left femur is 11mm longer than my right.
Here a Standing AP Pelvic Xray with Hip Replacement shows short left side at the hip level. This is not the patient who emailed.

I've been using a 12mm clearly adjustable heel lift for about a year. It has helped by I still have too much asymmetry.
Dr Blake's comment: For most of my athletes, you have to try and get as much lift full length as possible to hold the lift correct into the push off part of the gait cycle.
I agree with you that a full foot lift should be used. I've made a full foot lift out of a clearly adjustable lift. It is quite heavy and inconvenient to use so I never stuck with it.

I want to try a full foot lift similar to the ones you make.
Dr Blake's comment: You can buy rubber cork at JMS plastics (link below) in 1/8th inch sheets that work just fine.
So finally here are my questions that I would greatly appreciate that you answer.

What material do you make your lifts out of? I saw you referenced spenco. Is it the sepnco flat cushion inserts?
Dr Blake's comment: You can use the flat cushion inserts from Spenco that you see in many retail outlets or go to the rubber cork at JMS Plastics.

Are you familiar with clearly adjustable lifts? If so, why do you recommend yours over them.
Dr Blake's comments: I just have found them too slippery, and too thin. Most things I do the 3mm cork or spenco works just fine. Clearly adjustable are 1mm or so and seemingly harder to keep in place (but I have only seen 3 patients using them). It is safer to say I am more use to the other material and try to in general avoid heel lifts.

How much thickness is lost due your lifts compressing?
Dr Blake's comment: Probably lose 1mm every 6mm, but my patients love the softness, and both are grindable on a sander to make a smooth transition. The spenco can be ground on the black side.

How much thickness do you recommend for me? I'm thinking 9mm-3/8in since that is about the max for shoes and is close to my discrepancy.
Dr Blake's comment: Yes, but an extra 1/8th in the heel alone may be eventually added based on how you are feeling symptom and stability wise.
Lastly, knowing that it is 100% that my LLD is 11 mm and all in my femur; do you have any other recommendations that would help me out?
Dr Blake's comments: Definitely there are different combinations of muscle tightness and weakness based on the length difference all in the femur, all in the tibia, or combos. And, it is actually rare to have a pure structural leg length difference without a functional component of unequal pronatation, unequal knee rotation, pelvic assymetry, etc. It is in these areas that a good PT can greatly help you. The patterns of weakness and tightness may make sense because of your short leg, or that fact that you are right or left handed, or you had an old hip or shoulder injury years ago with some permanent restrictions at those areas. It is a fun area to help patients with.

Thanks so much,

You are welcome.

More Email Advice on Sesamoids

This email was received 1 month ago, so I am definitely behind, and for that I apologize.

Dr. Blake,

It's Victoria again (, and just wanted to thank you once again for your very thoughtful response and advice. I have began using the Exogen bone stimulator for 20 minutes a day, twice a day and incorporated contrast baths when possible.
Dr Blake's comment: When a fracture seems to have a chance at healing, consider a bone stimulator to help it along. The Exogen system uses ultrasound I believe and can be effective at 20 minutes twice daily.

I am really hoping for the best and doing all I can to avoid surgery, but I wanted to pick your brain to see what conditions have to exist for you to believe surgery really is the better option?
Dr Blake's comment: For most sesamoid injuries, no one would say you rushed into surgery if after 1 year you still had significant problems with disabilities (inability to do things that surgery may allow). That being said, many of my patients are on a good road to recovery at one year, and can see that they are making process, that it is very realistic they may not need surgery at all.

 Is there a time limit after which the bone likely will not heal?
Dr Blake's comment: Probably 5 years of continually seeing bone edema on the MRIs with associated pain, probably means that the situation is too far gone to avoid surgery. That being said, the pain may be from the fracture, the chronic swelling, scar tissue that develops, arthritic changes within the joint, etc. I know of too many of these injuries that the patient does great but the bone does not look perfect. So why do some patients continue to hurt and others not? This is the dilemma of the patient and doctor. At times in the treatment it makes sense to focus for periods of time at other causes of pain, while still protecting the bone. I remember a striking example of that during my initial years in practice. A patient presented with to me an obvious unhealing sesamoid bone requiring surgery. She had done all the standard treatments but not better. As I scheduled her for surgery, I also started her 3 times a day on contrast baths to make sure there was minimal swelling in the area at the time of surgery. She never had the surgery. The chronic swelling in the area, the actual cause of the pain at that time, was eliminated by the contrast bathing!! Good lesson.

If I opt not to do surgery, will I have the potential for sesamoid flare-ups the rest of my life such that it would be best to remove it and be done with it?
Dr Blake's comment: If you opt not to have surgery, that means you have developed a method to control pain and protect the sesamoid. Every day that passes the area will get less fragile and it will take more abuse to cause a set back. Controlling and watching and attempting to eliminate set backs becomes the main job for the next 2 years. With most of my patients, I am now 2 to 3 years out past the original injuries by now. If they are still having major periods of sesamoid woes that this time, I say enough is enough. This is probably less than 5% of patients (1 in 20) requiring surgery at this time.

 If I remove it, will it place more pressure on my remaining sesamoid bone?
Dr Blake's comment: Yes, so some protection of the other sesamoid for life is necessary. This normally is no big deal (sometimes a dancer's pad in a high heel will do the trick).

If my goal is to return to being able to wear heels, go salsa dancing in them, play tennis, and take up running again, which scenario would you steer toward?
Dr Blake's comment: If you plan on being very active following a sesamoid injury, and wear Lady Gaga-like heels, and play tennis like Serena, think save your sesamoid at all costs if possible. It is the saving of the sesamoid that allows the most normal post injury function, not in removing it to get on with life. Removing the sesamoid causes three problems (hopefully all minor, but you never know). These problems are: scar tissue, weakened joint, abnormal functioning joint, and possibly a surgical complication like infection, etc. Not removing the sesamoid may perserve the joint the way it was originally designed. So, unless the pain and disability can not be improved, but in slow cases taking several years, I always try to perserve.

There are so many variables that I could really use your advice on what the pros and cons are of either living with the hopefully-healed sesamoid versus surgically removing it.

Thank you in advance,
Dr Blake's comment: I hope this helps some, but you see it gets very individual. Mild pain to one person is sharp to another, mild disability to one is life changing to another. If you have done your due diligence and tried to save your sesamoid, and after 1 year you and your health care providers can not see a way to improve your disabilities, have it removed. The more I know about problems, because there are actual human beings attached with different sensitivities and goals, surgery or nonsurgical treatments become the way to individualize for each patient. Most medicine based protocols can be too limiting as the health care community learns more and more and more and more. For me, it would be easy to give up my 4 inch heels, but maybe not for you if that was what you were eventually asked to do (to avoid surgery or even after surgery).

Sesamoid Injury: Email Advice After Complete Removal Both Sesamoids

This is an email I received 3 weeks ago. I apologize for being way behind right now with no end in sight to catch up. Any advice I give in situations like this must be generalizations only, and may not truly apply the individual I am corresponding with. I do hope some of the information however will be very helpful. I must always defer to the health care provider that has personal knowledge of the case.

Dear Dr. Blake,

I recently discovered your blog...a bright light in the midst of my deteriorating foot odyssey!

Can you help me with orthotic fitter guidelines? I had a complete sesamoidectomy 10 years ago, resulting from a barn/equine accident that completely fractured both sesamoids. The podiatrist recommended removing both as the only option. I consented, not being fully informed of the problems sure to arise. Over time my great toe has drifted, exerting increasing leverage on the second toe. I have used toe separators, as well as regular stretching of scar tissue (yoga) and the crooked toe joint. I wore 3/4 length, rigid custom orthotics.
Dr Blake's Comment: Any surgery, on any joint, weakens that joint. Over time the weakened joint can shows signs of problems with changes in position (as commented here), pain, or problems elsewhere due to compensation for the weakness.

Metatarsal pain has developed over the past 3 months. I manage discomfort with Birkenstocks, Birkenstock inserts, layman's padding, and limited exercise. It was a very happy day when I discovered Hapads on your blog.

A respected orthopedic surgeon in my city suggested osteotomy for 1st metatarsal and toe joints, screws, etc, but I absolutely lack enthusiasm for foot surgery. He also recommended new orthotics for proper pain relief and foot stabilization. My radar went up as the fitter took imprints with a styrofoam box...needless to say they are not doing the job. They are full length, bulky, soft laytex fused to a cork bottom, wrapping around my heel and arch while providing remarkably little support. I miss the fit of my old orthotics as they beautifully supported my high arches.
Dr Blake's Comment: The Styrafoam box technique will always flatten the arch over a suspension cast taken in a non weight bearing position. Patients, and especially those with high arches, need to have all of that arch supported to take weight off the ball of the foot. It is the orthotist's job to maximally support that high arch while making it comfortable. Even though I have been doing this for 30 plus years, it can still take me several attempts to get it right in this situation. But, it can be done.
I'm left with these questions...

Can I prevent further progression of the dropping metatarsals?
Dr Blake's comments: Yes, definitely, si, and yes again. The right orthotic device along with foot exercises to strengthen your foot painlessly can make great improvements in your stability and stabilize the collapsing problem. Exercise routines like yoga and Tai Chi can also greatly help.

In my quest for range of great toe motion could Down Dog yoga position and plank position have contributed to metatarsal instability?
Dr Blake's comment: Yes, forced dorsiflexion of the big toe joint for prolonged periods could increase joint instability. However, it is not definite, and may have enabled you to go 10 years without significant problems post surgery. Do not give yourself any guilt on that one! From this point on, use painfree activities as safe activities for your foot.

Can an orthotic be made providing firm support for my arches, as well as off loading and softer suppport for the forefoot?
Dr Blake's Comment: That is the simple RX for any orthotic device for this problem: Off weight the sore area by transferring support to the arch, and soften/cushion the sore area in the front of your foot. Every orthotic maker knows these 2 basic rules.

Can I be sure an orthotic fitter knows how to accurately get an imprint of my feet?
Dr Blake's comment: Whether you use the same fitter, or another, at least you have these goals and a pair of orthotics that do not provide enough support. I have my preferences like semi-rigid plastic 3/4 th length for the arch support part, and then soft topcovers full length with accommodative forefoot extensions to float sore spots. It is hard to know if the orthotic fitter was accurate, but having a conversation per manufacturing around these 2 things should help you.

How can I find an excellent orthotic maker in my area?
Dr Blake's Comment: In the Indianapolis area, there is a great lab called Allied/OSI. My contact there is Darlene. She should know who is good, really good, to help you. The good people usually demand the most out of the lab, ask the most questions, etc. Should she not be available, talk to the lab owner, or plant director. They are known world wide for their expertise. Show them this email.

I appreciate any ideas you have. I am increasingly limited and deeply worried about further structural deterioration of my forefoot.
Thank you,

Indianapolis, Indiana...will travel to the right foot doctor and orthotic creator, especially Chicago and DC areas.

SFHipHopDanceFest: Welcome to Hip Hop

Had the pleasure of watching so many great performers last night at the SFHipHopDanceFest in San Francisco including our physical therapist Devon with Loose Change and these incredible performers from Chicago called FootworKINGz. They were Kings of Foot Work. As a podiatrist, I was in total admiration.

 These videos are from the 2007 SFHipHopDanceFest.

This is the 13th Annual of SFHipHopDanceFest and I plan on making many more. Congratulations to all the performers. And now here is Loose Change also from their 2007 performance.

Saturday, November 19, 2011

When Are Orthotic Devices Too Old and Should Be Replaced?

Collection of Custom Made Orthotic Devices

Patients present almost daily with orthotic devices made in the past  and want to know if they  are still okay to wear or should we make new ones. There are several common generalizations out there from every 2 years to every 5 years for rigid or semi-rigid orthotics, and every 6 months to one year for soft orthotics.
 I tend to take a different stand on this. First of all, I never want to see the orthotic (to avoid judging a book by it's cover) device until I have seen how the patient functions in it. Some pretty horrible looking orthotic devices work great and some high tech super duper ones look terrible at controlling the abnormal forces.
This week I had a patient Marilee in to evaluate her 20 year old orthotic devices, and they functioned just fine. I stole them for just one day to do standard refurbishing of the non plastic parts. And because she has somehow gone from 44 to 64 years old, I changed the posting on the heel to softer materials for more shock absorption. A little kinder on her knees which can bother her.
And there are times that new orthotic devices are made to change the purpose of the orthotic device used. So  basic orthotic devices used to stabilize the foot for plantar fasciitis in 1996 may not be stable enough or soft enough to help a knee problem in 2011.
Therefore, the general rules of keeping it simple stupid (KISS) do seem to apply here most of the time. The Orthotic Devices can be Too Old when they stop giving great function and allow the patient to walk and/or exercise better, when symptoms seem to be stubborn and orthotic changes may help, when new symptoms normally necessitate a different type of orthotic device all together, and of course, following foot/ankle surgery when the foot is now a different shape.
This only takes a little more thought than some protocol stating every 2 years or so whether the patient needs it or not. 

Friday, November 18, 2011

How You Carry Your Stuff May Not Be So Good

I chose Laurie because of how colorful she was here to demonstrate the principle of Equal Loading.

Most of us carry too much on one side of our bodies. I love to carry my gym bag always on my right shoulder, even when I was having left hip pain. Remember that the right shoulder works in harmony with the left hip and vice versa. It is important when you have musculoskeletal problems to see if how you typically carry your handbags, grocery bags, etc. has a negative or positive impact, and then make changes accordingly. Here  Laurie demonstrates the principle of Equal Loading to even out the pressure exerted by the contents of these bags.

By looking at Laurie, you can see that her right shoulder is lower and more rounded. This makes it easier to carry objects on her left shoulder. Since her problems primarily concern the left side, it is important to share loads equally on both sides. 

Thursday, November 17, 2011

ICD 10 Coding: Revolutionary Change in Medicine for 2013

This is a lecture I gave yesterday to my office on ICD10 Coding. This will revolutionize medical documentation in 2 years. I had been assigned/volunteered to give this lecture. I am hopeful some of my readers in medicine will gain from this. Rich I also wanted to prove that I have not been goofing off, but I am also looking to get my mojo back on the basketball court.

100 Points on ICD 10 Coding
by Richard L Blake, DPM

Starts 10.1.13 Only Applies to ICD, not CPT
Outpatient billing DOS 10.1.13
Inpatient billing starts date of discharge 10.1.13 or later
No Grace Period

Facts: I. Greater Specificity and clinical accuracy make ICD 10 easier to use than ICD 9
2. Because ICD 10 is much more specific, is more clinically accurate, and uses a more
logical structure, it is much easier to use than ICD 10.

3 to 7 characters in the new coding system
First Alpha (only U not used)
Second Numeric
Rest Either
X can be used as placeholder
A code that needs 7 characters is invalid without all 7
All codes are invalid if not correct number of characters
In codes longer than 3 characters, the decimal after the 3rd character
Alpha is not case sensitive
7th character used in certain chapters (obstetrics, musculoskeletal, injuries, and external
causes of injury)

Examples Of Codes

ICD 10 book divided Alphabet Index and Tabular List (must use both)
Alphabetical Index (not based on anatomy)
Index is divided into 2 parts: Index to Diseases and Injuries and Index to External Causes
3, 4, 5, or 6 characters with or without dash (-) The dash tells us if more characters are
Look for the dash.

Tabular List (based on anatomy)
Tabular List is subdivided into categories (first 3 characters), subcategories (4th and 5th
characters), and codes (3rd through 7th characters).
3 Character categories. Examples :
S90-S99 Foot/Ankle Injuries
R25-R29 Symptoms and Signs nerves and
R50-R69 General Symptoms and Signs

There are some categories that stand alone as legitimate codes.
Decimal always after these first 3 characters
4th and 5th increase specificity
5th and 6th Laterality
7th about visit itself

[ ] Brackets used in Tab List identify manifestation codes
( ) Parenthesis is non essential information
: Colon in Tab List signifies code needs more characters

Some Differences from ICD 9:
Laterality (side of the body affected) has been added to relevant codes
Expanded use of combination codes (certain conditions and associated common symptoms
or manifestations
Injuries grouped by anatomical site rather than type of injury
Codes reflect modern medicine and updated medical terminology

How to Code? First look up diagnostic terms in Alphabet, then verify in Tab. Read and
follow guidance given. Laterality and 7th character only in Tab. A dash (-) in Alphabet indicates
more characters needed. Even no (-) Tab to tell you if 7th character is needed.
5th or 6th character for Laterality
1 right
2 left
0 or 9 unspecified in the chart

Example of Laterality
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.519 Malignant neoplasm of lower outer quadrant of unspecified female breast

First: Report Code most responsible for the visit
Second: List Subsequent codes for co-existing conditions
Third: Code all documented conditions that exist, but not ones previously treated
and healed
Fourth: History codes if relevant are used Z80-Z87
Fifth: List Chronic diseases as long as applicable

Each code is reported once per encounter, even in bi lateral conditions, or in the situation where 2
conditions have the same code.
If the same condition is described in the medical note as both acute and chronic, and separate
entities exist in Alphabet, code both, with acute first.

Breakdown of Tab List
A/B Infections
C/D Neoplasms
D50-D89 Blood/Immune
E Endocrine/Metabolic
F Mental/Behavior
G Nervous
H Eye/Adnexa
I Circulation
J Respiratory
K Digestive
L Skin/SubQ
M Musculoskeletal /Connective Tissue
O Pregnancy/Childbirth
P Perinatal
Q Congenital
R Signs/Symptoms/Abnormal Tests and Findings
S/T Injury, Poisoning, External Causes
V External Causes of Morbidity
W Accidental Injuries
X Heat/Hot Substances
X92-Y09 Assault
Y21-Y99 Misc Causes of Morbidity
Z Factors Influencing Health Status

Before diagnosis established/confirmed, use symptoms and
signs, R codes.
If condition normally associated with the disease, do not need to code separately.

For Example:
Patient presents with pain and swelling on initial visit from gardening in the right knee.
The knee joint is too sore to adequately examine.
Since we can safely say she must have sprained her knee somehow, check Alphabet
under sprain , then knee, S83.9-
Then check Tab: S83.91x-
The x is a placeholder and the dash signifies I need a7th character. So, S83.91xA,
but this would be wrong!!!!!!!

Unless our PE is unbeatable, or we get an MRI on the first visit, we should use R codes until
diagnosis is solid.
R22.41 Localized swelling, mass and lump, right lower limb would work.
R52 Unspecified Pain would work
Neither of these require further specification and if you get an MRI soon the code
change would then reflect a more exact dx.
Since we found this patient could not bear weight, a secondary dx would be
Check Alphabet: difficulty, walking. R26.2
Check Tab: R26.2 is stand alone code ( has 2 excludes1 which can not be used with it)
Can we throw in Gardening, yes some of the Y codes work here. Y93.H2 Activity, gardening and

Diagnoses based on probable, suspected, rule out, etc does not
apply to outpatient coding.
In outpatient setting, first-listed diagnosis is used in lieu of principle
It may take 2 or 3 visits to establish diagnosis

So, on that gardener, so send her to PT with diagnostic codes R22.41 first-listed, R52 second,
R26.2 third, and Y93.H2. The therapy Rx will be designed to reduce the swelling while you await
approval for the MRI. Patients receiving Therapy only code chief diagnosis
first that is responsible for their visit. Other codes may be sequenced after.

When the MRI revealed torn posterior horn of the medial meniscus ,the Alphabet showed:
Injury,kneeS89.9- You are always supposed to check in Alphabet first.
Check Tab: search through S for exact dx S83.221A Peripheral Tear of Medial Meniscus, current
injury, right knee. The secondary dx of R26.2 still works. Gardening code also works. The swelling
code would not work since it is normally part of a torn meniscus diagnosis.

If we go back to our same gardener, when the Pre op is done the coding is Z01.81 Pre Op
Examination first with the reason for the surgery second
S83.221A (A should be okay since you are still working on the initial treatment )

During the Pre operative examination, an important history of past DVT was discovered, these
history codes can be found Z80-Z87. So, the 3rd code in the Pre op diagnosis
was Z86.71 Personal history of venous thrombosis and embolism. It should be listed since it
affects treatment.

Patients receiving Pre op only, sequence first a code from Z01.81. Describe a code for reason
surgery next. Code also any findings related to Pre op evaluation.
After surgery, Drs Susan Prieto and Victor Lewis were able to use their normal CPT codes since
they are not changing. The first post op visit again fell into the realm of Z codes Z47.89
Encounter for other orthopedic aftercare. And there are other more specific ones. Use the
reason for the surgery as the second code. For the aftercare of an injury, assign the acute injury
code (in this case S83.221-) with the 7th character D. S83.221D

Very Specific Coding: (many are used routinely in sports medicine)
Infectious Agents
Infections resistive to Antibiotics
Endocrine, nutritional, metabolic
Nervous System
Pressure Ulcers
MusculoSkeletal/Connective Tissue
Signs,symptoms, Abnormal clinical findings/lab findings
Orthopedic Aftercare in Z category with 100s other misc patient encounters

Musculoskeletal/Connective: M Codes
Most codes have site and Laterality
Site represents bone, joint, or muscle.
If more sites, multiple site code used. If need, use multiple codes when multiple site code absent.
If both bone and joint affected, use bone.
M codes: When to use them
Conditions from healed injury
Recurring conditions
Chronic conditions

Example: Osteoporosis Rules
Not Site specific (no injury at present) use M81 Category
If associated fracture, site must be identified
Z87.31 personal history of osteoporosis fracture should follow
M81 codes
M80 codes identify the site of the fracture
M80.08xA means initial visit age related pathological
fracture vertebra current

R codes: When to use them
Symptoms, signs, and abnormal clinical and lab,not elsewhere
classified R codes
Could be Ill-defined conditions
Acceptable before diagnosis established
Can be used after diagnosis code, if not normally associated
Special falling codes
R29.6 Repeated falls after recent fall
Z91.81 History of Falling (for at risk) when appropriate both used together
Special coding SIRS (systemic inflam response syndrome)

S Codes: When To Use Them
Current Acute Injury (see the example above of the torn meniscus)
Injuries S codes
Most with 7th character
A Initial Encounter. While receiving active treatment before the healing can begin
(may take multiple visits)
D Subsequent encounter. For routine care during healing/recovery phase
This is for cast changes, medication changes, other Follow up visits.
The aftercare Z codes are not to be used here.
S Sequela. For complications direct result of injury like ex scar after burn. You must use
both injury code and sequela code.S is added to the injury only. Sequela listed first,
than injury.
Assign separate codes for each injury, unless combination code exists.
Traumatic injury codes S00-T14.9 not for normal healing surgical wounds or surgical
Code for most serious injury first
Superficial injuries not coded if deeper injury at same site.
When primary injury also damages superficial nerves and blood vessels, code primary injury first.

Coding for Traumatic Fractures:
Fractures of multiple sites are to be coded individually.
If not indicated in the medical record, consider the fracture closed and displaced
7th Initial Encounter while active treatment even if delayed seeking treatment
A initial closed fracture
B initial open fracture
D subsequent encounter fracture normal healing
G subsequent encounter fracture delayed healing
K subsequent encounter fracture non union (also M and N)
P subsequent encounter fracture mal union (also Q and R)
S sequela
Multiple fractures should be sequenced for severity

Z Codes for patient encounters other than a disease or injury
Like Orthopedic Aftercare

More on Understanding the Lingo:
And means and/or
With means associated with or due to
See means another term must be looked at for the correct code to use
See Also not essential for coding
Both codes can never be used together
Indicates that the code identified in the medical record and code used by the physician can not
be reported together because the 2 conditions can not occur together

E10 Type 1 Diabetes Mellitus
Excludes1: diabetes mellitus due to underlining condition E08.-
drug or chemical induced diabetes mellitus E09.-
gestational diabetes O24.4-
hyperglycemia NOS R73.9
neonatal diabetes mellitus P70.2
type 2 diabetes mellitus E11.-

Another Example:
M21 Other Acquired deformities of limbs
Excludes1: acquired absence of limb Z89.-
congenital absence of limbs Q71-Q73
Both conditions may occur at same time, so both codes may then be used.
Indicates that condition identified in the medical record is not part of the condition
represented by the code used by the physician, so that both codes may be reported together
if the patient has both conditions

L89 Pressure Ulcer
Excludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622,
E11.621, E11.622, E13.621, E13.622)
non pressure chronic ulcer of skin L97.-
skin infections L00-L08
varicose ulcer (I83.0, I83.2)

Another Example:
I70.2 Atherosclerosis of the native arteries of the extremities
Excludes2: atherosclerosis of bypass graft of extremities (I70.30-I70.79)
Other or other specified means specific code not exist
Unspecified codes med record not identify more specific
Inclusion Terms means conditions to use code but not exhaustive
Use Additional Code in Tab where another code could more fully describe condition. You
Must use when present, but you need to use last.
Default Code: code listed next to main term in Alphabet. Condition most connected to main
term. If med record not specify another term, use default.
Follow Alphabet guidance coding syndromes.

Code first/use additional code /in diseases classified elsewhere
Etiology codes must be first
Manifestation codes second
In diseases elsewhere means this is the manifestation code
In the Alphabet List, both codes listed together with manifestation codes in brackets.
Code Also
Two codes may be necessary/order discretionary

What is a combination code? Single code for 2 diagnoses, diagnosis with manifestation,
or diagnosis with complication. Combination codes are found in sub term entries Alphabet, and
reading inclusion and exclusion notes in Tab. They are to be used over multiple codes. Can also
be used with additional code.

Late Effects (sequela) after acute over. No time limit on reporting. Condition of late effect
coded first, late effect code second. Exceptions: when late effect code needs manifestation codes
(Tab), or has been expanded (-) to include manifestation. Code for acute phase never used with
late effect code.

Special coding at the time of discharge for impending or threatening conditions.
Nonspecific codes ( “unspecified” or “NOS” which is “not otherwise specified”) are
available to use when detailed documentation to support more specific code is not available.

ICD 10 Coding Examples:
Type 1 diabetics mellitus with diabetic nephropathy
First Check Alphabet:
Diabetes, diabetic (mellitus) (sugar) E11.9
type 1 E10.9
nephropathy E10.21
Then Verify in Tabular List:
E10 Type 1 diabetes mellitus
E10.2 Type 1 diabetes mellitus with kidney complications
E10.21 Type 1 diabetes mellitus with diabetic nephropathy

First Check Alphabet:
Hypertension, hypertensive (accelerated) (benign)
(essential) (idiopathic) (malignant) (systemic) I10
Verify Code in Tabular List:
E10 Essential (primary) hypertension
Includes: high blood pressure
Excludes1: hypertensive disease complicating pregnancy, childbirth, and
puerperium (O10-O11, O13-O16)
Excludes2: essential (primary) hypertension involving vessels of the brain
essential (primary) hypertension involving vessels of the eye

Friday, November 11, 2011

Heel Spurs: Some Are Just Not That Bad!!

Here is the Bottom of a Heel Bone with a very large bone spur. The patient was told to have that removed due to the pain it was causing. The patient sought a second opinion, thus I came briefly into the picture. The spur seen on the bottom of this heel is typical. It does not run to the bottom of the foot stabbing anything. It actually lies parallel and above the plantar fascia. It is not irritating anything, but is a by-product of 20 plus years of excessive pull of the plantar fascia on the bone. It is a calcium buildup, in a non-weight bearing part of the bone, a sign of chronic plantar fascial irritation, but not what causes the problem. This particular patient has had a spur for 20 years developing, and pain for 3 months only. No great correlation. Avoid being talked into heel spur syndrome when the heel spur probably is not really the real source of your present pain. 

Thursday, November 10, 2011

Sever's Disease: Growth Plate Injury in a Child's Heel

     The above photo is of the heel bone in a 12 year old boy. The heel bone is called the "calcaneus" and has an important growth plate at the base. Boys from 8 to 14 and Girls 7 to 13 can have pain develop in this area either from the pull of the achilles tendon, or the pull of the plantar fascia. After those ages, the growth plates fuse and there can no longer be a source of pain. With my 2 boys growing up, and playing tons of sports, both had this problem. Ice soaking (see separate post) for 20 minutes twice daily really minimizes the soreness, but you must start as soon as the soreness begins. At least they could just dip their heel into the ice water, not the entire foot. We always joked as they iced that they were now guaranteed to grow more.

     The basic rule is to create a pain free environment with no limping. Hopefully, they can continue playing, but the parents and coaches must watch for limping/favoring.  Electrical Stimulation with ice is a good physical therapy modality along with achilles stretching without pain. If you look closely at the photo, you can see how the achilles tendon attaches right on it, and can irritate it endlessly. Some form of heel cushion or lift, if it makes it feel better, is also helpful. 

     I will always remember Alex, short for his age at 10 years old, less than 5 foot tall,  and with one of the worse, long-lasting, stubborn cases I have treated. The symptoms remained significant for almost one year. When all was said and done, by 14 years old,  he was 6 feet 2 and still growing. 

Wednesday, November 9, 2011

Onychomyosis: Toe Nail Fungus

The photo demonstrates the use of a small piece of gauze laid down on the toenail with fungus. The gauze is big enough just to cover the nail. The gauze is soaked in white vinegar, squeezed to remove excess, and then laid on top of the nail. Paper or scotch tape is used to hold the tape in place for several hours in the evening, 3 to 5 times per week. This is done for the 6 to 9 months it takes to allow a new nail to grow out. Hopefully, you are happy with the fungus free new nail. Vinegar is 5% acid and fungus can not live in it. Once per week it is good to pumice the top of the toenail (s) to thin out as much as possible over a 6 month period. 

Tuesday, November 8, 2011

The Ballet Blog: Looks Like a Great Site

Here is a Ballet Question I get asked all the time. When is a safe for my daughter to go en pointe? 
My typical answer is 12 years old when there is enough skeletal maturity and when the child has enough strength to maintain proper technique (normally after 3-5 years of training) throughout the entire class. Poor technique leads to bunions, hammertoes, pain in many areas. Dr Rich Blake

Monday, November 7, 2011

Want Stronger Bones: Think Purple??

Please read this article on developing stronger  bones.  There's so many ways of developing a more enduring skeletal system to help us through our youth and aging process.

Sunday, November 6, 2011

More Testimonials for Triathlete Coach Marc Evans

MEC Testimonials from World Class Coaches
A central mission of MEC is cooperating with coaches of all levels. MEC works with coaches to help their athletes perform better through extensive biomechanic, movement and technique analysis.
MEC is an accessible and highly regarded resource for coaches, teams, clubs and athletes that will enhance their coaching to athletes by providing some of the best movement and technique coaching available.
MEC (Marc Evans) is available to travel to your area, provide extensive coaching services in the Lake Tahoe area and/or clinics/camps/workshops at your selected venue.
We are a partner with some of the best names in sport; coaches who know that using MEC helps their athletes reach successful outcomes.

Dave Scott
Boulder, Colorado
Triathlon: 6 time World Ironman Champion 
"I've known Marc Evans for nearly thirty years as a coach, teacher and advisor for endurance athletes.  Marc's unique skill set has extended the boundaries of physiology and biomechanics which has allowed him to assess, advise and manage athletes of all abilities.     He has an unparalleled approach in dissecting the nuances of an athlete's limitations whether the cause is directly related to overuse, fatigue, instability in joints or muscle imbalances.  Developing the knowledge base in working with hundreds of athletes, Marc has a vast repertoire that only comes with hands on experience.  His wizardry in working with athletes is truly a gift." 

Karlyn Pipes-Neilsen
Kailua-Kona, Hawaii
4-time World Masters Swimmer of the Year
Coach and President: Aquatic Edge, Inc.
"Coach Marc Evans is a true master of triathlon with the unique ability to blend the complex science of sport with simple, back-to-basics common sense. Even though Marc has spent most of his life as a hugely successful coach and author, he does not rest on his laurels. 
Marc tests and re-tests his theories and has the ability to adapt and change as new information becomes available making him one of the most sought after coaches in the world." 
Matt Dixon
San Francisco, CA
Elite coach and owner of Purplepatch Fitness. Coach of Matt Lieto and a stable of elite endurance athletes
"Marc has been a great resource for several of my professional athletes looking to take their technical and functional components of performance to an elevated level.  It is great to have a resource of Marc's technical expertise to help complete the assessment and prescription of technical evolution."

Do You See The Knee Alignment Problem On The Left Side???

This patient presents with bilateral bowlegs.  You can see in this photo that the left leg has more of a Bowing  at the knee joint.  This produces a compression force on the inside of the knee and a stretching on the outside of the knee.  If this patient presents with inside or medial knee pain, you must be concerned with medial compression syndrome.  Orthotic devices which oversupinate  the foot, can produce this effect even in a normal patient.  Due to the stretching of the outside or lateral side of the knee, ilio–tibial band syndrome is quite common.

Tip for Adding Lift/Stability to an Orthotic Device

When Adding Lifts for a short leg or some other purpose to the bottom of some custom made devices, and most over the counter insoles,  consider making the lifts like the insert on the left. First you glue on 1/8th inch rubber cork from JMS Plastics or another supplier to both sides, then you cut and smooth (if you have a method of grinding). See the photo below.

This nice young lady has achilles soreness on both sides. Her inserts were wearing down slightly allowing more motion in gait. I placed the medial and lateral heel buttresses to both sides for extra side to side stability and also to achieve the heel lift effect to relax the pull of the achilles. A straight heel lift can produce more instability as it lifts the patient out of the shoe slightly.