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Thursday, June 6, 2019

Medicare and Podiatry

Medicare and Podiatry how are you covered?
Podiatrists are doctors who specialize in conditions pertaining to feet and ankles. They can treat anything as simple as an ingrown toenail to plantar fasciitis. Aging adults are prone to chronic foot problems, especially if they have an underlying disease such as diabetes.
However, Medicare doesn’t cover all podiatry services. In fact, Medicare doesn’t cover routine foot care at all. For other podiatry services such as treating specific conditions and surgeries, Medicare has specific rules for coverage. First, let’s discuss what isn’t covered by Medicare.

Podiatry Services Not Covered by Medicare

Medicare doesn’t cover routine foot care except in situations where another health condition requires it, such as diabetic neuropathy. Routine foot card includes, but is not limited to, corn removals, debriding toenails, and maintenance care. Another condition that Medicare doesn’t cover any podiatry services for is flat foot.
Medicare also doesn’t cover supportive devices such as orthopedic shoes unless they are included in the price of a leg brace or the patient has diabetes. Medicare doesn’t cover these services because they are not considered medically necessary.

Podiatry Services That May be Covered by Medicare

Medicare will cover podiatry services that are considered needed to diagnose or treat a medical condition. Conditions such as hammer toes, heel spurs, and bunion deformities yield Medicare coverage for treatment.
Diabetes patients get a little more leeway when it comes to foot care because they have a greater risk of developing foot conditions. Therefore, if you have diabetes, you can receive a foot exam once every six months as long as you have been to a podiatrist for any other reason within those six months.
As we briefly mentioned above, Medicare will also cover services that are otherwise considered routine if you have an underlying disease. For instance, if you have peripheral vascular disease, a disease that reduces blood flow to your feet and other limbs, routine podiatry services may be covered. Other diseases and conditions that may validate routine foot care coverage are Buerger’s disease, peripheral neuropathies, and Arteriosclerosis obliterans.
Mycotic nails can be common in the aging community. Mycotic nails are nails that are yellow-brown in color, with a thick and brittle texture, and are usually infected with fungus. Medicare may cover treatment for mycotic nails if your doctor documents clinical evidence of infection, and you are showing symptoms such as pain or secondary infection.

How You’ll Pay for Your Podiatry Services Through Medicare

Podiatry services are usually performed in a doctor’s office in an outpatient setting. Medicare Part B covers medically necessary outpatient doctor services and therefore, will be in charge of your podiatry services.
Part B will pay 80 percent of your medical costs. You will be responsible for both an annual deductible of $185 and 20 percent of the bill. If you receive any treatments in a hospital as an outpatient, you will likely experience a copay as well.
If you ever require surgery to treat a foot condition and you are admitted in the hospital on an in-patient status, Part A will come in effect as well. You will have a $1,364 deductible for your hospital stay that will pay for your hospital services such as your room and meals.
This deductible will also cover your first 20 days in a skilled nursing facility (SNF) if your doctor recommends you finish your recovery there. Medicare will only cover your SNF stay if you were admitted to the hospital for at least 3 days.
When you apply for Medicare, you may want to consider supplemental coverage to help pay for things like this. Medicare plans such as Medigap and Medicare Advantage can help lower some of these costs. Medigap plans can help cover your Part A deductible and Part B deductible, copays, and coinsurance.
Medicare Advantage plans can help lower your out-of-pocket costs by setting a copayment amount that may be lower than your normal Part B coinsurance. Medicare Advantage plans also often offer extra podiatry services, such as routine foot care exams.
In summary, Medicare will cover podiatry services as long as they can be deemed medically necessary. If you’re unsure about whether your specific service will be covered, ask your podiatrist.

Monday, June 3, 2019

Big Toe Joint Pain: Diagnostic and Treatment Dilemma

Hi, Dr. Blake, 

I came across your blog and immediately felt the urge to ask you for your opinion on my foot condition. 

I am 38 years old woman and have been dealing with pain under the ball of the foot for a year. At first it was on the side of the ball which lead the orthopedist to think it was due to hallux valgus. 
But the joint was also swollen, so I did an MRI which showed a suspected "fracture" on the medial sesamoid bone, which could be a state after trauma.
Dr. Blake's comment: The one MRI view you sent me looked normal. What was the report? 
I got custom made orthotics (5 variations) and ate a box of Arcoxia, but after several weeks the pain was only worse. I do not have pain if I touch or press on the ball, but when I walk, the whole area is kind of sore. I walk on the outside of the foot, which I think makes it even worse - also the soft tissues around the ball are kind of stiff, I have to massage them. Some days it better, some its worse. 
Dr. Blake's comment: Start doing ice pack 10-15 minutes twice daily, and contrast bathing starting at one minute heat one minute ice for 20 minutes each evening. Non painful massage is wonderful 2-3 minutes and 2-3 times a day. Are the orthotics off weighting the area of the ball of the foot enough? 

I try not to walk a lot, since the condition gets worse after several minutes of walking. I can't do hiking or running anymore. I ride a bike, do Pilates (but no planks!), I also go swimming, but there is also pressure on the foot when swimming, so its not perfect. 
Dr. Blake's comment: this is great while you wait for healing to cross train. 

I made another MRI in January 2019: 
"In the distal part of the medial sesamoid bone transverse is a moderate hyperintense line. The bone structure of the distal pole of the sublingual bone is somewhat non-homogeneous, somewhere hyperintensive ________ (there is a word missing in a report). The proximal part of the sesamoid bone has normal signals also on the contact surface. It could be a bipartite sesamoide bone with degenerative 
changes in the distal core, less likely for a condition after an old injury."

Dr. Blake's comment: Try to send more images. You can send 8-9 that shows sesamoid bones for the 3 MRI directions.

The doctor said that MRI is not very clear, and it clinically looks like sesamoiditis, but that it's strange that it doesn't hurt when he presses on the area. He suggested PRP (platelet rich plasma).  Do you have any experience with it curing sesamoiditis?
Dr. Blake's comment: No, has promise for tendons and fascia. You do not know what is wrong yet. It would be very experimental and guess work at this point. 

I also tried taping the foot which helps a bit, physiotherapist did a laser, which kind of helped, but he said it's no use coming back, since it will be always be worse when I walk again. He suggested MBT shoes. 
Dr. Blake's comment: Start doing the normal stuff for sesamoids right now: Hoka Shoes with the rocker, cluffy wedges, dancer's padding, some arch support, spica taping. Do them all and limit walking this month June to day to day what you have to so. Work on the inflammation with ice, contrasts, arnica lotion. See if you can not turn this around. 

I visited 3 doctors and one of them said there's nothing you can do besides custom orthotics and 2 of them (which were private) said, they would try with PRP. A trauma doctor gave me a cortisone injection which didn't help at all. 
Dr. Blake's comment: stay away from cortisone if we do not know what is wrong yet. What lead up to this pain developing? Were you walking too much? Did you bang it? Are you a terrible pronator? 

I am very confused since I don't even know what is wrong and I am reading all about the different diagnosis over the web and different treatments, but my doctors don't seem to know anything about this possibilities. I was never offered a walking boot or suggested a period of immobilization. I asked about the option of doing some additional research, but he said he could do a scintiography, but it would only show if there is any inflammation, but would not show the cause. 
Dr. Blake's comment: I actually think the scinitiography would be great to see if the bone lights up. Definitely, walking in a removable boot (you can purchase the Anklizer type) at least to help you do more walking every day would be great. You have to place dancer's pads some times. Even if you wore only for the 4 hours per day that you are on your feet that would be helpful. If you feel off balance, get an Even Up for the other shoe. 

I'm also reading about contrast baths, HBO program, shock treatment therapy, Exogen bone stimulator (which I mentioned to my orthopedist, but he said, "you can't stimulate if there is nothing broken ...")
 ... but I am no doctor and I really don't know if any of these treatments would be good for me.  Non of the doctors I have visited haven't advised me anything of it. Custom orthotics, PRP and finally operation if all fails, that is all.
Dr. Blake's comment: Contrast bathes, usually one minute hot and one minute cold for 20 minutes in the evening is good to reduce swelling, while ice just controls it. 

Can you give me some advise? What is my problem, fracture, degeneration ...fragmentation ...?
Could I have AVN?
Dr. Blake's comment: need more images for sure. In general, when the sesamoid is injured, it is really sore on light palpation, so we have to make sure you even have a sesamoid injury in the first place. 

A big thank you in advance, I can't wait to read your opinion.

And when I did not answer (as I am taking a lot of vacations this year):

Hi, dr. Blake, 

I was just wondering if you got my email? I really could use an advice from someone experienced as you in this area. 
Since the condition hasn't got any better, I received a PRP injection last week. I asked the doctor about non-weight bearing and if I should use a walking boot and he said there is no need to. I am so confused, because I read on your blog that all other patient are supposed to not bare weight during a period of time. 
Dr. Blake's comment: The goal is to do what you can to control the pain to 0-2 levels. Typically, only really acute injuries need non weight bearing. Normally, I love the removable boots, anti-inflammatory measures, and activity modification to protect the area while the diagnosis is being made. 

After 6 days the area is swollen and sore, yesterday I even stepped a bit too hard on that area and experienced sharp pain (I am trying to not step on it at all, having custom made orthotics and dancers pads  and walking on the outside of the foot) and now it even more sore. 
Dr. Blake's comment: Non weight bearing typically makes the swelling worse, so protected weight bearing is better with the boot. Any step you take pushes fluid out of the foot. Occasional sharp pains are okay, as long as they only hurt temporarily. 
Do I ice it or do contrast baths or not? I am supposed to have another shot in a week, but I am not really sure if I should do it, since there is no improvement yet. 
Dr. Blake's comment: See above comments on ice and contrasts, get the boot ($60 on amazon), get the scintiography if you can, send me more images. Do non painful massage several times a day. Send me a photo of the top and bottom of both feet now. 

I would be very happy for your opinion.
Thank you

Saturday, June 1, 2019

Chronic Metatarsal Pain: Email Advice

hello dr Blake,
I am writing all the way from Italy and was wondering whether you could be so kind as to help shed some light on a foot problem I've been struggling with for the past 5 years. I hope you enjoy puzzles! I'm 33 years old, male, 6' 4'', 165 pounds. 

5 years ago I suffered a minor injury which caused capsulitis on my 1st MTP joint (right foot). Eventually the capsulitis resolved, but at the same time I gradually started to experience additional discomfort on the same foot for reasons which in hindsight seem to be attributable to increased weight/pressure on the affected foot when walking. For example, the metatarsal pad of the orthotics I had been prescribed to treat the capsulitis after a few months started to be painful (whereas with my left foot I could barely feel it), and after I switched to a pair without the met pads (April 2016), the discomfort shifted to other areas of my forefoot (sometimes lateral, sometimes medial, and always when pushing off). Sometimes I had the unpleasant sensation of 'feeling' my metatarsals when walking. Fed up with the orthotics, I tried to go back to walking without them as I had always done for 30 years. After a few days of walking pain-free I thought the condition had finally resolved and everything was back to normal, but shortly after the old symptoms came back. 
     So I went to see a podiatrist (January 2018), who said that my discomfort was due to unilateral over pronation and that I needed semi-rigid orthotics. The new orthotics worked very well for a couple of days, but then again symptoms-wise I was back to square one, with modest improvement. The podiatrist then made me a rigid pair of orthotics, but again, very little changed. Since he couldn't see any structural faults he came to the conclusion that the problem was muscle-related, more specifically my right calf was weak. This was maybe due to the original injury, since the capsulitis made it painful to push off as usual and so probably I started to use my calf muscles less and less. Nowadays I can rise on my toes on a single leg but I find it much easier with the other limb. I signed up at the gym, carried out a 4-month program with a fitness instructor (nothing specific for my problem though), experienced some improvements but very discontinuous, and finally went to see a physiotherapist (March 2019).
     The PT noticed a number of compensation patterns on the affected side, mainly internal rotation of the leg, pelvic tilt, an overactive tibialis anterior, and something about my latissimus dorsi which on that side was working harder than normal to maintain balance. I did 5 sessions where they manipulated mainly my pelvis and trunk, the reasoning was that all of those imbalances were affecting my foot, and not vice versa. On some days I noticed a definite improvement, but again, a bit discontinuous, so eventually they referred me to a podiatrist they knew in order to rule out intrinsic foot problems (April 2019, i.e. this week). 
Dr. Blake's comment: First of all, I am sorry I am late answering. You are not overweight and I am not sure that their is any association with the original capsulitis. All of your symptoms could be related to your unilateral pronation. If you look at your two orthotics, are they asymmetrical, with more support to the unilateral pronation side. 
     The podiatrist noticed a number of things apart from the unilateral over
pronation (ligamentous laxity, not much forefoot fat pad, big toe tends to make little contact), but the main thing seemed to be that the affected leg is 0.4" longer).  Thus, I would need a new pair of orthotics that took all of these things into account. I have no qualms about that, and I am willing to believe that 0.4" could go a long way to adding weight on my leg and foot and contributing to the problem. The affected leg is probably a bit longer, my fitness instructor once filmed me while walking on a treadmill and it clearly showed that the affected leg tended to circumduct (is that a verb?), and the anatomical leg length discrepancy may be compounded by a functional one.
Dr. Blake's comment: Yes, the long leg tends to be the more pronated, and 11 mm is a lot. I tend to try to separate the orthotic therapy and the lift therapy. So, I would gradually over one month build you up under the short side. When the patient is more pronated on the long side, correcting that aspect will make that side even higher, so you may need up to 1/2 inch. 

     I am willing to accept all of this. What I really can't wrap my mind around (and this is my main question) is this: if it really is a matter of bearing too much weight on the affected foot then why did it become symptomatic only in recent years, after the original injury? If the leg length discrepancy is truly anatomical, shouldn't I have had similar problems before the injury as well? The injury itself was no big deal, I hit a curb with my big toe but no fractures, just the capsulitis. Until 5 years ago I had never had the slightest problem. Could compensatory postural adjustments or lower leg muscle weakening post-injury have played a role in adding further weight to the affected side?
Dr. Blake's comment: Yes, for sure, an injury can cause other stresses to manifest for the first time. I am never sure if it is due to the deconditioning from the injury, or the compensations from the injury, but it happens all the time. I joke to my patients that at least it will stop after the third area begins to hurt (sometimes they get my humor). The long leg does put more stress on that foot for sure, and if you add the tightness that develops in the achilles with injuries, the stress to the injured foot can be quite bad. 

I'm adding a few bits of info which might help:
  • I tend to feel much less discomfort when walking barefoot (Dr. Blake's comment: for sure, shoes for sure add stress across the metatarsals as we try to bend at push off. Only stress fractures and other bruises hurt worse barefoot. This of course could be a clue for you to try very flexible shoes in the forefoot)
  • x-rays and MRI have always come out 'clean' (Dr. Blake's comment: Negative MRIs to me mean nerve injury first until ruled out. Nerve injuries show negative MRIs. Have you had any nerve symptoms like numbness, sharp, tingling, buzzing, electric, etc. It is also a good sign for the future as you do not have early onset arthritis).
  • pedograph analysis showed more pressure on the affected foot when walking, thought barefoot they were even (Dr. Blake's comment: Many times the difference only shows up running as are bodies have a harder time distributing the weight evenly.)
  • I tend to think that I am bearing more weight on the affected foot, but there are no signs of that on my skin (there is a slight degree of 'hallux valgus' though, could that be a sign?) Dr. Blake's comment: Yes, unilateral bunion formation or hammertoe formation is a sign of more stress.
  • as I mentioned before the discomfort I have on my forefoot is quite changeable, most times it's on the head of my 5th metatarsal, sometimes it's bit generalized, other times I don't feel anything on the 5th metatarsal and it's more on the big toe. In any case, it's always during push off. Dr. Blake's comment: The variability is more a stress syndrome than an injury. Change the mechanics, get stronger with single leg balancing and metatarsal doming, and stretch the achilles tendons several times a day. 
  • judging from what I see and from the pedograph analysis the arch of the foot seems fairly normal
I would be really grateful if you could share some thoughts on all of this, I've been through so much and am getting a bit depressed

thank you
Dr. Blake's comment: I hope you are feeling better. Get more flexible, get stronger, get at least 1/4 inch full length lifts and see if you are better with these changes. Rich 

The patient then answered:

hello dr Blake,
thank you very much for answering. I am writing a follow-up email to let you know how I am doing. If you feel to add any ideas or suggestions that I could pass on to the professionals that are looking after me (also in terms of diagnostic tests) I would be even more thankful (I have made a small donation to your blog as a token of gratitude). I don't want to take advantage of your kindness so if I don't receive further communications I will fully understand.
Over the last month and a half I have been wearing the new pair of orthotics (they have a 5 mm heel lift on the shorter leg, so the lift is not full length), my gait has improved as now I find it easier to push-off (last pair of orthotics were rigid and with little padding), while symptoms have also improved a bit but have not resolved. I am still doing physical therapy and next Wednesday I have a check-up with my podiatrist so I hope to clear things up a bit, but in the meantime I have been doing some research on a number of topics and I have come up with some new elements that may be worth mentioning. As my foot is apparently subjected to increased stress, I'm trying to understand what is causing it.
Dr. Blake's comment: Explain to the podiatrist to perhaps experiment with another orthotic device for the short side without the lift attached and with 2 (1/8th inch) full length spenco or other soft material as lifts one full length and one cut at the toes (sulcus length). That will add cushion but not pitch you forward as much onto the metatarsals. If you use soft material as lifts, you typically can go up a mm or 2 due to the compression. 
One of the working hypotheses is that it may be bearing more weight for some reason, but I've noticed this is something that hardly ever pops up in podiatry or PT. I have read several textbooks and at the most they talk about asymmetrical weight distribution foot-wise (i.e. more lateral or medial) and not body-wise (i.e. right leg/left leg).
Dr. Blake's comment: One method of getting some idea of the right to left weight bearing is looking at old inserts, ones that you have worn awhile, to see if one side is broken down more. The other common method is to stand evenly on two bathroom scales that you know are equally calibrated. Try to stand with equal weight in your mind, and have someone else take the measurements of left and right side. As soon as you look down to read the scales, you throw off this technique. It is only one tool, other than more sophisticated force plates/mats, but seems to be helpful. 
 I am wondering whether muscular imbalances in terms of tightness/weakness between the two halves of the body might play a role in how weight is distributed or force is transmitted to the lower extremities but I haven't been able to find any bibliography on the matter. Also studies on LLD and body weight distribution seem conflicting as to which leg bears more weight, so it's all a bit confusing to me. I did another pedobarographic analysis last month which apparently ruled out this asymmetrical weight-bearing hypothesis, as it showed that mean pressure was actually higher on the healthy foot when walking barefoot, but I don't know if such a test is supposed to be conclusive on this matter.
Dr. Blake's comment: I am not aware of any research on this matter, so I apologize. When a patient is bearing more weight on one side because of short leg syndrome, scoliosis, tight hamstrings or calves, weak muscles, etc they create postural instability as they try to compensate. This postural instability can lead to the measurements varying from step to step, with one side greater with one step, and the other side greater with the next step. Or, something like this. The force plate analysis as an office tool makes it difficult unless you do the test multiple times, and a definite pattern emerges. Most researchers feel you must walk over the force plate 10 or more times even to begin to practice the landing. This is actually why in a busy office I have not purchased these, but I understand their help in many situations. 

You mentioned in your reply to check for neurological signs, and this is something I didn't include in my first email. I do think there is something going on in that regard as well. One sign involves the dorsal aspect of the big toe, so I don't know if it's related to the general problem (forefoot plantar discomfort) but nonetheless it's worth mentioning. Sometimes I feel a mild burning sensation coursing along the big toe which is (sometimes, not every time) elicited if I move my leg after a period of inactivity when seated or lying down, and on sitting down after a walk.
Dr. Blake's comment: This is classic L4 nerve root irritation.

Or, also, when I'm doing sit-ups with my leg fully extended. What makes me think it's neurological is the fact that this burning sensation is sometimes elicited by stimulating the anal area (e.g. when I wipe after going to the bathroom), a very distant area that is directly connected to the foot only by means of nerves. I know that the deep peroneal nerve innervates the first web space and that it can get irritated when sitting with your legs crossed (something I used to do), but that doesn't match 100% my symptom in terms of location, as it's more dorsal 1st toe rather than 1st web space, and the peroneal/sciatic nerve is more 'buttock' than 'anus'. This burning sensation started post-injury, and I definitely remember that a few years ago sometimes I felt it coursing down my medial calf, on the side. Might it be that some nerve got irritated/damaged with the injury (big toe stubbed against a sidewalk) or consequent capsulitis? I know also that overpronation can cause tarsal tunnel syndrome but in that case symptoms involve the arch/ankle (not my case).
Dr. Blake's comment: This is up to a neurologist to put together, but sounds very neurological. The dorsal of the foot is irritated by tying your shoes too tight or above the knee problem like tight hamstrings, piriformis, or low back, not the tarsal tunnel. 
On the other hand though it's puzzling because other than the burning feeling I've never experienced the classic neurological telltale signs, i.e. tingling/numbness/electrical sensation, and it's something which is elicited with specific motions, and never at rest or at night.

All of this dorsal-big-toe-burning-symptom, though, as I said may not have much to do with the general problem, but I have come to think that there might a neurological component in the plantar aspect as well. Might it be that some plantar nerves are being compressed/being put under stress for some reason, and that weight-bearing pressure is 'felt' much more than usual? On the other hand, as I said before, the telltale signs of neuropathy are absent, and even on forceful palpation the sensitivity of my foot appears normal, so to my layman eyes it appears more a matter of stressed soft tissue than nerves.
Dr. Blake's comment: You have some minor nerve problem, and nerve problems cause a hyper-sensitivity that can make something hurt more at the foot. This is called "Double Crush". Definitely worth to check out, and right now deal with them separately. I hope I have helped and thank you for the donation. Rich

Again, thank you very much for your reply and for any further help you can provide