1 00:00:02,960 --> 00:00:06,200 Hi, Doctor Belton here. I'm going to do a staff training 2 00:00:06,200 --> 00:00:09,960 today, staff and doctors training about all the office 3 00:00:09,960 --> 00:00:13,600 procedures that we do and all the treatments that we do. 4 00:00:13,600 --> 00:00:15,680 I'm going to go over. It's kind of a comprehensive 5 00:00:17,120 --> 00:00:20,160 explanation, but I think many people just don't know exactly 6 00:00:20,440 --> 00:00:23,720 what the treatments are. This can be for the back office 7 00:00:23,720 --> 00:00:26,480 staff, so they know kind of what we're doing and also for the 8 00:00:26,480 --> 00:00:28,440 front office when people are checking out and they're getting 9 00:00:28,440 --> 00:00:31,240 these procedures. So we're going to go over all of 10 00:00:31,240 --> 00:00:34,240 these procedures. They're in alphabetical order. 11 00:00:34,760 --> 00:00:38,960 So I'm going to put a link in a lot of these. 12 00:00:38,960 --> 00:00:42,760 There's going to be these little links where you can learn more 13 00:00:42,800 --> 00:00:44,080 if you want to. These are going to go to 14 00:00:44,080 --> 00:00:47,480 different Google patient education things that we do. 15 00:00:47,840 --> 00:00:51,240 So let's start out aspiration of assist. 16 00:00:52,200 --> 00:00:54,720 This is where there is a cyst in the in the foot. 17 00:00:54,720 --> 00:00:57,080 Usually it's coming from a joint or a tendon sheath. 18 00:00:57,080 --> 00:00:59,760 It looks like a big bulb on the skin. 19 00:00:59,760 --> 00:01:03,760 It can be different places to aspirated or to take out the 20 00:01:03,760 --> 00:01:07,040 liquid prevent we we use anesthesia, so we anesthetize 21 00:01:07,040 --> 00:01:09,440 the area. Usually it's right on the top of 22 00:01:09,440 --> 00:01:14,720 the skin, right over it first, and usually one CC is enough. 23 00:01:15,640 --> 00:01:19,120 And then what we do is we take an 18 gauge needle with the same 24 00:01:19,120 --> 00:01:22,760 syringe or a bigger syringe, usually 3:00 to 5:00 or 10CC 25 00:01:22,760 --> 00:01:25,720 syringes and you pull out all the liquid that's in there and 26 00:01:25,720 --> 00:01:29,000 that should deflate this. This can be sometimes done with 27 00:01:29,000 --> 00:01:33,600 ultrasound and then afterwards you apply compression, a 1-2 or 28 00:01:33,600 --> 00:01:37,160 three inch coban. 1 inch tends to be for toes, 3 inch tends to 29 00:01:37,160 --> 00:01:40,480 be for the foot and they'll keep that on there for repeating it 30 00:01:40,480 --> 00:01:44,520 once a day after they shower for two weeks and then usually do a 31 00:01:44,520 --> 00:01:48,480 two week follow up for this. That's what a a cyst removal. 32 00:01:49,920 --> 00:01:52,680 How that is in the foot. There's a high chance of 33 00:01:52,680 --> 00:01:57,040 recurrence with cyst removals and if it doesn't resolve doing 34 00:01:57,040 --> 00:01:59,800 it like two or three times then then a lot of times we'll we'll 35 00:01:59,840 --> 00:02:02,000 we'll surgically remove the cysts, but even with surgery 36 00:02:02,240 --> 00:02:06,960 there's a high recurrence rate. Next thing would be biopsy of 37 00:02:06,960 --> 00:02:09,320 the skin. Many of our patients they have 38 00:02:09,320 --> 00:02:13,480 skin dermatitis or or athletes footer tiniapetus or eczema or 39 00:02:13,480 --> 00:02:15,240 other types of things that haven't resolved. 40 00:02:15,560 --> 00:02:19,080 They may have tried something topically already like an like 41 00:02:19,080 --> 00:02:23,440 an antifungal cream. What we what we tend to do for 42 00:02:23,440 --> 00:02:26,320 skin is we do one CC of lidocaine with epinephrine. 43 00:02:26,320 --> 00:02:29,280 The reason for the epinephrine is because it it doesn't bleed 44 00:02:29,280 --> 00:02:31,240 as much. So you would just put a little 45 00:02:31,240 --> 00:02:34,080 bit of a little a little bit underneath. 46 00:02:34,080 --> 00:02:37,520 Usually you want to do the the edge of the of the area that 47 00:02:37,520 --> 00:02:43,080 you're going to biopsy and you do 2-2 punch, two 2mm punch 48 00:02:43,080 --> 00:02:45,440 biopsies. That's the easiest for most. 49 00:02:45,640 --> 00:02:49,160 The reason 22 millimeters are done is because you are because 50 00:02:49,160 --> 00:02:53,560 you don't need to do a suture Many times with 3mm or 4mm you 51 00:02:53,760 --> 00:02:55,200 have to put it, you have to put a stitch in there. 52 00:02:55,480 --> 00:02:57,800 So it's just easier to do 2 of them and and they heal a little 53 00:02:57,800 --> 00:03:00,960 bit better and they give you two different parts of the of this 54 00:03:00,960 --> 00:03:03,720 area. You use it to identify any 55 00:03:03,720 --> 00:03:05,640 dermatitis athlete's foot rashes. 56 00:03:06,040 --> 00:03:10,000 You may try something topically before but if that doesn't work 57 00:03:10,000 --> 00:03:12,320 then you can do this. I usually do a two week follow 58 00:03:12,320 --> 00:03:15,000 up or go over the results and you make sure everything heals 59 00:03:15,000 --> 00:03:16,360 normally. These heal pretty well. 60 00:03:16,360 --> 00:03:18,400 This is 1 type of a biopsy. We're going to go over a few 61 00:03:18,400 --> 00:03:23,360 other types of biopsies as well. This is a from a previous 62 00:03:23,360 --> 00:03:28,680 lecture talks about CPT codes. There's if we do two of them, 63 00:03:28,680 --> 00:03:32,080 you have to do an initial CPT and then the subsequent biopsy. 64 00:03:32,480 --> 00:03:35,800 Here are some reasons that we would do it and some of the 65 00:03:35,800 --> 00:03:38,560 things we talked about before. It's usually a smaller part of a 66 00:03:38,560 --> 00:03:40,720 larger lesion. This is how you do it. 67 00:03:40,720 --> 00:03:42,840 You you kind of go down you punch it in there. 68 00:03:43,040 --> 00:03:46,160 Be careful when you're removing it from the plunger right here 69 00:03:46,440 --> 00:03:50,760 to not crush it. It goes in from formalin their 70 00:03:50,760 --> 00:03:53,320 full thickness. They're going to heal by what we 71 00:03:53,320 --> 00:03:56,480 call secondary intention, which means that he'll just be on 72 00:03:56,480 --> 00:04:00,360 their own. If it's over 3mm then then you 73 00:04:00,520 --> 00:04:03,720 usually do a suture for pigmented lesions, which are 74 00:04:03,720 --> 00:04:06,400 like things we're worried about, Melanoma, you're going to do A 75 00:04:06,400 --> 00:04:09,400 larger biopsy can be used and you have to. 76 00:04:09,440 --> 00:04:11,320 You have to mark the position on the foot. 77 00:04:12,360 --> 00:04:16,680 So might take a picture. You might take a suture and put 78 00:04:16,680 --> 00:04:19,880 a suture in the biopsy site to determine what's anterior 79 00:04:19,880 --> 00:04:25,560 posterior in what, what time. Usually like 12:00, three 80 00:04:25,560 --> 00:04:30,720 o'clock, whatever o'clock it is. If you're doing that, we also 81 00:04:30,840 --> 00:04:34,280 can use curitage that's using a curette. 82 00:04:34,840 --> 00:04:39,760 This is typically used between the the toes. 83 00:04:39,760 --> 00:04:42,040 So if there's a build up in there, white build up, it could 84 00:04:42,040 --> 00:04:44,000 be athlete's foot, could be another condition called 85 00:04:44,040 --> 00:04:46,360 erythrasma. And we test this with a woods 86 00:04:46,360 --> 00:04:49,800 lamp where you take that little, there's a little black or blue 87 00:04:49,800 --> 00:04:52,200 light that we have and it makes it fluorescent. 88 00:04:53,040 --> 00:04:54,640 You scrape the surface and you can send off. 89 00:04:54,640 --> 00:04:58,240 There's no need for anesthesia, but it's it's difficult to get 90 00:04:58,240 --> 00:05:00,200 anything deep with that. So we just usually use this 91 00:05:00,200 --> 00:05:02,920 between the toes. There's another couple of 92 00:05:03,200 --> 00:05:06,160 options of doing shave biopsies. We do less shave biopsies. 93 00:05:07,320 --> 00:05:10,200 If there's a lesion we're removing, it's usually where 94 00:05:10,200 --> 00:05:14,880 we're cutting out a wart which shave doesn't usually get deep 95 00:05:14,880 --> 00:05:17,320 enough, but this could be for a little elevations in the skin. 96 00:05:17,320 --> 00:05:19,000 You can get the whole lesion out there. 97 00:05:19,000 --> 00:05:22,400 Usually we use the 15 blade, this is called a. 98 00:05:23,000 --> 00:05:25,520 It's like a flexible blade. I think we have some of these in 99 00:05:25,520 --> 00:05:26,920 the office that you can use as well. 100 00:05:28,400 --> 00:05:31,360 A nail biopsy. This is done right here. 101 00:05:31,360 --> 00:05:33,760 Here's an example of a 3mm biopsy that we did. 102 00:05:35,480 --> 00:05:38,160 This is after like a few months after because it's because it's 103 00:05:38,160 --> 00:05:43,800 growing out and it's it's used to evaluate Melanonokea. 104 00:05:44,680 --> 00:05:47,640 This is a black line in in the toe nail. 105 00:05:47,960 --> 00:05:51,240 If we're concerned about Melanoma, we will do a biopsy at 106 00:05:51,240 --> 00:05:55,120 the at the nail base. You do a block of the toe, 107 00:05:55,120 --> 00:05:57,280 meaning you numb up the toe in the back just like you would do 108 00:05:57,280 --> 00:06:01,360 for an ingrown toenail. For nail biopsy we usually do a 109 00:06:01,360 --> 00:06:06,600 bigger one, so a 3mm one, but we don't need to do a suture and 110 00:06:07,920 --> 00:06:10,160 you're going to evaluate you do a two week follow up and usually 111 00:06:10,160 --> 00:06:13,760 this grows out well without injuring without injuring the 112 00:06:13,920 --> 00:06:18,840 the growth plate. With a nail biopsy it's that's 113 00:06:18,840 --> 00:06:23,160 normally for dark discoloration. Just a reminder, nail samples 114 00:06:23,160 --> 00:06:25,640 aren't considered biopsies. So taking a sample for funguses 115 00:06:25,640 --> 00:06:31,960 in a biopsy, you're usually doing a toll block for that a 116 00:06:31,960 --> 00:06:34,000 nail sample. This is what we typically do in 117 00:06:34,000 --> 00:06:36,760 the office we used to evaluate nail fungus for discolored 118 00:06:36,760 --> 00:06:38,120 nails. What I tend to do is when the 119 00:06:38,120 --> 00:06:40,880 patients have their name on a little piece of paper, I just 120 00:06:40,880 --> 00:06:43,440 take that paper, stick it on the little plastic bag that we have 121 00:06:43,440 --> 00:06:45,360 in the bottom drawers and I take a little trimming. 122 00:06:45,360 --> 00:06:48,720 That's why I would, I would trim distally here on the nail, put 123 00:06:48,720 --> 00:06:52,040 it in the plastic bag, put what toe it is and then and I would 124 00:06:52,040 --> 00:06:55,120 do the fill out the the biopsy within the within the medical 125 00:06:55,120 --> 00:06:56,360 record. So you always have to put it in 126 00:06:56,360 --> 00:06:59,480 the medical record what area you're doing and then that's 127 00:06:59,480 --> 00:07:03,480 sent out and I put their name on there from the from the little 128 00:07:03,840 --> 00:07:06,920 post it notes that we use it's this isn't considered a biopsy. 129 00:07:06,920 --> 00:07:09,040 I tend to see patients back in two weeks where I would go over 130 00:07:09,040 --> 00:07:12,800 the results with them even even though many times we think it's 131 00:07:12,800 --> 00:07:15,240 fungus, a lot of times it can be due to trauma or to other 132 00:07:15,240 --> 00:07:16,600 things. So it's not always a fungus. 133 00:07:16,600 --> 00:07:18,920 That's the reason we take the nail sample and especially if 134 00:07:18,920 --> 00:07:21,240 I'm going to be putting someone on an oral medication, I like to 135 00:07:21,240 --> 00:07:26,000 use a nail sample. Very rarely we do this as well. 136 00:07:26,000 --> 00:07:27,280 This would be a needle aspiration. 137 00:07:27,280 --> 00:07:28,840 So we talked about a cyst before. 138 00:07:29,440 --> 00:07:33,440 With a cyst you could, you could biopsy that so you could use 139 00:07:33,440 --> 00:07:36,040 imaging which would be ultrasound for soft tissue 140 00:07:36,040 --> 00:07:40,000 lipoma or a ganglion cyst. If you don't get anything then 141 00:07:40,000 --> 00:07:42,560 you would just flush out with the specimen jar. 142 00:07:43,360 --> 00:07:46,080 So let's say you try to pull something out of a soft tissue 143 00:07:46,080 --> 00:07:47,360 mask, but you can't get anything out. 144 00:07:48,360 --> 00:07:51,360 You can still take what's in there and you you kind of draw 145 00:07:51,360 --> 00:07:54,440 up the formalin and you push it back in and that could put in 146 00:07:54,440 --> 00:07:56,200 some of the content. So you can send that. 147 00:07:57,040 --> 00:07:58,880 You have to create back pressure or a vacuum. 148 00:07:58,920 --> 00:08:01,080 You can see how it's pulled out with the fingers right here 149 00:08:01,080 --> 00:08:02,680 you're pulling it out. That's creating back pressure as 150 00:08:02,680 --> 00:08:05,160 you're pulling it. You go into different quadrants 151 00:08:05,160 --> 00:08:07,800 because many times these lesions are what we call lobulated. 152 00:08:07,800 --> 00:08:09,640 So there's different little chambers in them. 153 00:08:09,640 --> 00:08:12,000 So as you're pulling it out, you're pulling out for the 154 00:08:12,000 --> 00:08:14,120 quadrants. If you don't see anything, once 155 00:08:14,120 --> 00:08:16,520 again you, you drop the fixative, which is the formalin, 156 00:08:16,560 --> 00:08:18,360 and you squirt it back in the specimen container. 157 00:08:18,360 --> 00:08:22,400 So that's what we do for, for these aspirations of soft tissue 158 00:08:22,400 --> 00:08:26,480 masses. OK, other procedures that we do, 159 00:08:26,520 --> 00:08:28,720 there's a procedure, we just call it a procedure, but it's 160 00:08:28,720 --> 00:08:30,760 brace dispensing. So that's done with the doctor. 161 00:08:30,960 --> 00:08:33,080 This is a visit with the doctor when we're dispensing the brace, 162 00:08:33,080 --> 00:08:34,720 the reason we do it with the doctor because we want to make 163 00:08:34,720 --> 00:08:35,919 sure it fits. We'll make sure they have the 164 00:08:35,919 --> 00:08:38,280 right shoes. And we also bill the insurance 165 00:08:38,280 --> 00:08:40,080 at that visit. So we don't bill it when we 166 00:08:40,080 --> 00:08:42,559 order it. We bill the insurance when we 167 00:08:42,559 --> 00:08:46,800 dispense it and you need to make sure it fits well. 168 00:08:47,000 --> 00:08:49,600 Giving them shoe guidance is is the of the utmost importance. 169 00:08:49,600 --> 00:08:52,480 We give them a handout that has some information about shoes but 170 00:08:52,480 --> 00:08:56,480 typically they have to go up a half size and they they also may 171 00:08:56,480 --> 00:08:58,960 need to do an extra depth shoe or something similar. 172 00:08:58,960 --> 00:09:02,440 These patients tend to be in like a an ortho feed or a doctor 173 00:09:02,440 --> 00:09:05,560 comfort shoe or a depth shoe or something that's a little bit 174 00:09:05,560 --> 00:09:08,240 bigger. One thing to remember, patients 175 00:09:08,240 --> 00:09:10,280 have a six week follow up and you have to be careful of any 176 00:09:10,280 --> 00:09:11,560 rubbing. So if there's any rubbing on the 177 00:09:11,560 --> 00:09:14,840 skin, you have to be careful. They should be seen that sooner. 178 00:09:15,200 --> 00:09:18,560 And they can get a new brace every five years unless their 179 00:09:18,560 --> 00:09:20,120 foot changes. So if their foot gets more 180 00:09:20,120 --> 00:09:24,440 collapsed, it gets more swollen, increased deformity where things 181 00:09:24,440 --> 00:09:27,640 don't fit. Then you can evaluate something 182 00:09:27,640 --> 00:09:30,200 called same and similar and try to get a brace that's that's 183 00:09:30,200 --> 00:09:32,040 newer. This is an example of a Ritchie 184 00:09:32,040 --> 00:09:34,720 brace for a patient. We have to be careful that 185 00:09:34,720 --> 00:09:36,840 there's no rubbing with these. That's especially important. 186 00:09:36,840 --> 00:09:41,040 A patient is diabetic or neuropathic casting. 187 00:09:41,280 --> 00:09:43,400 This is something that we do frequently post operatively. 188 00:09:43,400 --> 00:09:45,800 There's a little cast stand that we use, so all the materials 189 00:09:45,800 --> 00:09:48,200 should be prepared. It's done in the office. 190 00:09:49,520 --> 00:09:52,120 Sometimes patients might come in with a bivalve cast that just 191 00:09:52,120 --> 00:09:55,080 means it's cut down the side and then you put an ACE wrap around 192 00:09:55,080 --> 00:09:57,160 it. That's to allow for more 193 00:09:57,160 --> 00:10:00,160 swelling initially, but then when we put a cast on, we'll put 194 00:10:00,160 --> 00:10:02,320 it on and take it off every week to two depending on the amount 195 00:10:02,320 --> 00:10:03,960 of swelling. If they have a lot of swelling, 196 00:10:04,080 --> 00:10:06,480 they'll take it off in a week because the swelling will come 197 00:10:06,480 --> 00:10:10,720 down with a cast and it'll it'll it'll piston, meaning it'll move 198 00:10:10,720 --> 00:10:12,640 up and down and that could cause irritation. 199 00:10:13,560 --> 00:10:17,080 Usually we use 3 rolls of cast material and we use the the cast 200 00:10:17,080 --> 00:10:19,920 and sometimes we put a little peg underneath it to help the 201 00:10:19,920 --> 00:10:21,520 patient. This is done by the doctor, but 202 00:10:21,520 --> 00:10:23,280 the setup is done done by the staff. 203 00:10:24,920 --> 00:10:27,680 Focused shockwave, they're two different types of shockwave. 204 00:10:27,680 --> 00:10:30,360 We have in our in our Westboro office, we have the focused and 205 00:10:30,360 --> 00:10:32,440 the radial. I'll talk about all of them 206 00:10:32,440 --> 00:10:33,960 here. So the difference between 207 00:10:33,960 --> 00:10:36,400 focused and radio focused is electrical waves. 208 00:10:36,400 --> 00:10:39,080 It has very good bone penetration and it's used to 209 00:10:39,080 --> 00:10:42,120 speed up healings of fractures, stress fractures, areas that 210 00:10:42,120 --> 00:10:44,920 have bone marrow edema that's noted on an MRI. 211 00:10:45,640 --> 00:10:48,040 It can help with arthritis pain, but it doesn't restore the 212 00:10:48,040 --> 00:10:50,440 cartilage, so it can help with the swelling underneath the 213 00:10:50,440 --> 00:10:53,640 bone, the bone marrow edema. It uses electrical pulses. 214 00:10:53,680 --> 00:10:58,040 It can be done by itself if it's purely a bone issue, but many 215 00:10:58,040 --> 00:11:07,160 times it's done with radial, radial shockwave and here is 216 00:11:08,760 --> 00:11:10,840 radial shockwave. This one has a little piece of 217 00:11:10,840 --> 00:11:14,760 metal that goes back and forth here and it creates these radial 218 00:11:14,760 --> 00:11:16,720 shock waves that penetrate into the skin. 219 00:11:17,560 --> 00:11:21,160 It's used to help areas of chronic or acute injury. 220 00:11:21,160 --> 00:11:24,080 It can be used for chronic like chronic issues like plantar 221 00:11:24,080 --> 00:11:26,640 fasciitis, Achilles tendonitis, other types of tendons. 222 00:11:26,920 --> 00:11:30,800 It tends to work really well on on soft tissue and it's all can 223 00:11:30,920 --> 00:11:33,320 also can be used for acute things like an ankle sprains and 224 00:11:33,320 --> 00:11:35,720 things like that as well Hips the way I kind of explained it 225 00:11:35,720 --> 00:11:39,400 to patients is it helps he speed up the healing process by 50 by 226 00:11:39,400 --> 00:11:44,080 50% and it's 82%. I know Doctor Savius is like 89% 227 00:11:44,080 --> 00:11:46,680 effective depends on what it is. Very very rarely is it 228 00:11:46,680 --> 00:11:49,120 uneffected. It's not usually used in 229 00:11:49,120 --> 00:11:51,200 isolation, so you're doing other treatments as well. 230 00:11:51,600 --> 00:11:54,680 It's good for plantar fasciitis, Achilles tendon issues, 231 00:11:54,680 --> 00:11:58,120 swelling, ankle sprains, neuropathy, arthritis, not, not 232 00:11:58,120 --> 00:12:01,120 so successful for neuropathy and arthritis is the other things. 233 00:12:01,600 --> 00:12:03,320 Usually you do three to six sessions. 234 00:12:03,680 --> 00:12:06,080 The way I kind of explain to patients, if it's been over six 235 00:12:06,080 --> 00:12:08,160 months, I say they'll probably need 6 sessions. 236 00:12:08,160 --> 00:12:09,680 If it's under six months, they'll need 3. 237 00:12:10,080 --> 00:12:11,720 Some of the doctors go right to four. 238 00:12:12,280 --> 00:12:14,320 It really depends. But some of these chronic issues 239 00:12:14,320 --> 00:12:16,840 that you need more time and it takes about six weeks before 240 00:12:16,840 --> 00:12:19,000 they see improvement. So the benefit of doing 6 241 00:12:19,000 --> 00:12:22,400 sessions is that when they come in at the 6th one, they start to 242 00:12:22,400 --> 00:12:24,560 feel better. So what I what I tend to find is 243 00:12:25,240 --> 00:12:28,120 after they finish, I'll say you'll start have more good days 244 00:12:28,120 --> 00:12:31,120 than bad days. You can't have Motrin or similar 245 00:12:31,120 --> 00:12:33,240 medications for two days before and two days after. 246 00:12:33,240 --> 00:12:34,760 And we tend to do weekly appointments. 247 00:12:35,000 --> 00:12:36,000 It's kind of like going to the gym. 248 00:12:36,000 --> 00:12:37,840 So you don't want to do it once a month because you're not going 249 00:12:37,840 --> 00:12:39,880 to see the benefit like going to the gym you should go every week 250 00:12:40,120 --> 00:12:42,240 because you're you're it's going to be tissue breakdown and 251 00:12:42,240 --> 00:12:44,640 tissue repair. So it can go up to two weeks, 252 00:12:44,640 --> 00:12:46,560 but usually it doesn't go beyond that. 253 00:12:46,560 --> 00:12:48,200 And it can even be sooner than weekly. 254 00:12:48,200 --> 00:12:49,800 It can be every two or three days as well. 255 00:12:49,800 --> 00:12:54,240 If you want the effects of shockwave, a couple of the most 256 00:12:54,240 --> 00:12:56,400 important things that we tell patients. 257 00:12:56,400 --> 00:12:59,280 It stimulates circulation. OK, Micro circulation is 258 00:12:59,280 --> 00:13:02,320 important to healing. You don't really need to know 259 00:13:02,320 --> 00:13:05,840 these other things. Release of substance P just 260 00:13:05,840 --> 00:13:07,800 means there's reduced pain in the tissues. 261 00:13:08,560 --> 00:13:12,800 It stimulates growth factors like new growth of blood 262 00:13:12,800 --> 00:13:16,040 vessels, bone and cartilage, and it stimulates stem cells. 263 00:13:16,520 --> 00:13:18,680 So it recruits kind of the stem cells in that area. 264 00:13:18,720 --> 00:13:21,080 So it's not injecting stem cells, but it recruits that. 265 00:13:21,080 --> 00:13:23,160 That's why it heals things that aren't healing. 266 00:13:23,640 --> 00:13:26,040 And for patients, a lot of times they're walking on their foot 267 00:13:26,040 --> 00:13:27,760 and they just never have a chance to heal or it keeps 268 00:13:27,760 --> 00:13:30,000 injuring it. So that's why we support it with 269 00:13:30,000 --> 00:13:32,160 like an orthotic or or a brace or a boot. 270 00:13:32,440 --> 00:13:34,320 And then we we use this treatment to help it heal 271 00:13:34,320 --> 00:13:39,400 faster. The shockwave process, initially 272 00:13:39,400 --> 00:13:42,200 we evaluate it usually with an ultrasound so we can see the 273 00:13:42,200 --> 00:13:45,080 damaged tissue. We do three to six sessions. 274 00:13:45,360 --> 00:13:49,680 They're done weekly, they're 7 to 10 minutes, avoiding NSAID's 275 00:13:49,680 --> 00:13:51,720 a six week break. During this time there's a 276 00:13:51,720 --> 00:13:55,600 repairing of the tissue and this starts after six weeks. 277 00:13:56,160 --> 00:13:58,760 This is the time where I usually send them to physical therapy 278 00:13:58,760 --> 00:14:00,760 during that six week interval and then I've seen them back 279 00:14:00,760 --> 00:14:03,880 after six weeks and we see the improvement and if we want to, 280 00:14:03,880 --> 00:14:05,120 we can look at it with an ultrasound. 281 00:14:05,120 --> 00:14:08,640 Again, with ultrasound, I tend to charge for the first 282 00:14:08,640 --> 00:14:11,000 ultrasound, but I don't tend to charge for the subsequent ones 283 00:14:11,240 --> 00:14:13,960 if they're paying out of pocket. But if insurance covers it, then 284 00:14:13,960 --> 00:14:17,280 I'll bill it and it takes about six months for everything to 285 00:14:17,280 --> 00:14:20,960 remodel. And so you just have to tell 286 00:14:20,960 --> 00:14:25,560 patients to be patient radial and focused We tend to do 287 00:14:25,560 --> 00:14:28,120 together. It helps to speed up the 288 00:14:28,120 --> 00:14:30,040 healing. We only have both of these in 289 00:14:30,040 --> 00:14:32,120 Westboro right now. It can also be done with pain 290 00:14:32,120 --> 00:14:33,560 laser. There's also a pain laser that 291 00:14:33,560 --> 00:14:36,280 we have Remi pain laser. So we could do the all the 292 00:14:36,280 --> 00:14:44,320 combination talk a little bit about office visits just just 293 00:14:44,320 --> 00:14:47,160 for simplicity. Sometimes we'll be putting this 294 00:14:47,160 --> 00:14:50,640 on the notes, but just for kind of staff training typically for 295 00:14:50,640 --> 00:14:52,400 established patients, there's new patient visits and 296 00:14:52,400 --> 00:14:56,360 established, so established or anyone that hasn't has been here 297 00:14:56,360 --> 00:15:00,000 and and new patients anyone hasn't seen this in, in more 298 00:15:00,000 --> 00:15:02,520 than three years, OK. If it's been less than three 299 00:15:02,520 --> 00:15:03,920 years, it's an established patient. 300 00:15:04,640 --> 00:15:08,520 I cannot keep it simple. A level 2 visit is is typically 301 00:15:08,520 --> 00:15:11,560 a quick follow up where you're not really going in depth that 302 00:15:11,560 --> 00:15:13,880 much. This is very high level overview 303 00:15:13,880 --> 00:15:16,600 here, but it like a parenchia follow up matrix, follow up, 304 00:15:16,880 --> 00:15:18,800 infection follow up when everything is doing well. 305 00:15:19,120 --> 00:15:21,680 Level 3 visit is where we spend most of our time, Level 3 and 306 00:15:21,680 --> 00:15:23,920 level 4 for like a diabetic foot exam. 307 00:15:24,360 --> 00:15:27,840 Just a reminder for a diabetic foot exam, we tend to they put 308 00:15:27,840 --> 00:15:31,840 in the billing not diabetes but normally the condition that 309 00:15:31,840 --> 00:15:34,360 we're that we're looking at. So it let's say they have 310 00:15:34,360 --> 00:15:38,280 diabetes but they also have an ingrown toenail or or hammer toe 311 00:15:38,280 --> 00:15:42,720 or something else like that. And when you need more treatment 312 00:15:42,760 --> 00:15:45,280 than and the current treatment is not that simple, let's say we 313 00:15:45,280 --> 00:15:48,520 order physical therapy, we order other types of treatment, we 314 00:15:48,520 --> 00:15:50,600 decide on shockwave, we decide on something else. 315 00:15:50,840 --> 00:15:55,920 Level 4 is more complex or I kind of kind of keep it if I'm 316 00:15:55,920 --> 00:15:59,960 doing a prescription, so I'm doing a a a anti-inflammatory or 317 00:15:59,960 --> 00:16:02,240 antibiotic or something like that or renewing a prescription 318 00:16:02,240 --> 00:16:04,560 that's going to be a level 4. Or if you're doing like surgical 319 00:16:04,560 --> 00:16:06,960 discussion what you're tending to do prescriptions or planning 320 00:16:06,960 --> 00:16:08,120 to do prescriptions at that time. 321 00:16:08,120 --> 00:16:11,120 So just a simple overview of some of the billing things. 322 00:16:12,720 --> 00:16:15,800 A benign lesion excision, which is like removing a wart. 323 00:16:16,120 --> 00:16:18,360 This is an example of a wart where we would numb it up with 324 00:16:18,520 --> 00:16:22,920 anesthetic, with epinephrine so there's no bleeding and then we 325 00:16:22,920 --> 00:16:25,240 would excise that. That could be anything else. 326 00:16:25,320 --> 00:16:28,200 Many times for excisions, we'll use in a Mira gel post op kit. 327 00:16:28,360 --> 00:16:30,800 Post op kits can be used not just on ingrown toenails, they 328 00:16:30,800 --> 00:16:32,160 can be used for like wart removals. 329 00:16:32,160 --> 00:16:33,800 They can be used for matrixectomies. 330 00:16:33,800 --> 00:16:36,120 They can be used for other wounds that aren't that deep. 331 00:16:36,920 --> 00:16:40,640 I tend to send anything we take out of the body like a lesion. 332 00:16:40,640 --> 00:16:43,840 I'll tend to send a pathology. The only times I wouldn't, let's 333 00:16:43,840 --> 00:16:45,760 say they're like a self paid patient and they would have to 334 00:16:45,760 --> 00:16:48,200 pay for that pathology evaluation which can tend to be 335 00:16:48,200 --> 00:16:51,440 expensive and then we'll do a two week follow up for them. 336 00:16:53,440 --> 00:16:56,840 Here's an excision in nail and nail matrix which we call a nail 337 00:16:57,920 --> 00:16:59,760 matrixectomy. That's what this is called. 338 00:17:00,840 --> 00:17:02,520 It's used for chronic ingrown toenails. 339 00:17:02,880 --> 00:17:05,599 Someone has a chronic issue, they might have swelling on the 340 00:17:05,599 --> 00:17:07,079 side or they might just have callous buildup. 341 00:17:07,240 --> 00:17:09,760 What we do is we take out the edge and we put a chemical which 342 00:17:09,760 --> 00:17:13,160 is in our office, sodium hydroxide and and then that 343 00:17:13,160 --> 00:17:15,599 doesn't grow back. It's used to remove the side of 344 00:17:15,599 --> 00:17:18,200 the nail or even the entire nail if they don't like it due to a 345 00:17:18,200 --> 00:17:20,560 fungal nail. The common complications are 346 00:17:20,560 --> 00:17:24,079 infection, which is quite rare. It's not really that common. 347 00:17:24,240 --> 00:17:26,319 So I always tell patients there's going to be redness, 348 00:17:26,319 --> 00:17:29,480 there's going to be swelling down at the base and they're a 349 00:17:30,360 --> 00:17:32,200 spicule can happen. This isn't a spicule. 350 00:17:32,200 --> 00:17:35,000 So spicule is a piece of nail that grows back after a 351 00:17:35,000 --> 00:17:37,560 matrixectomy because it didn't work completely and you can 352 00:17:37,560 --> 00:17:40,280 remove that again and do another matrixectomy on there. 353 00:17:40,280 --> 00:17:43,920 We tend to do a two to three-week follow up when if 354 00:17:43,920 --> 00:17:46,520 you're less busy you can do 2-2 or four week. 355 00:17:47,160 --> 00:17:49,240 If you're busier you can do one at 3 weeks. 356 00:17:49,520 --> 00:17:50,520 OK. And then we also can have 357 00:17:50,520 --> 00:17:52,600 patient text us a number if they have concerns. 358 00:17:54,200 --> 00:17:55,840 This is an example of an exostectomy. 359 00:17:55,840 --> 00:17:59,360 An exostectomy is an area of bone, usually it's between the 360 00:17:59,360 --> 00:18:01,800 4th and 5th digits where it's kind of macerated and there's 361 00:18:01,800 --> 00:18:03,720 pain in there usually due to a bone spur. 362 00:18:04,320 --> 00:18:07,200 And the treatment for this certainly is spacers, wider 363 00:18:07,200 --> 00:18:09,200 shoes. But then if that doesn't work we 364 00:18:09,200 --> 00:18:11,880 we we shave down the bone. So you would shave down the bone 365 00:18:11,880 --> 00:18:14,680 on the side. We usually use a metallic marker 366 00:18:14,680 --> 00:18:17,320 when we get an X-ray for this to determine where the bone is. 367 00:18:17,720 --> 00:18:20,000 And then you would put a, you would just make a little 368 00:18:20,000 --> 00:18:23,480 incision on top or at the tip and you would use the rasp to go 369 00:18:23,480 --> 00:18:26,240 in there and shave that down. And then that would kind of 370 00:18:26,240 --> 00:18:28,600 resolve that. You can't get it wet for two 371 00:18:28,600 --> 00:18:30,920 weeks because there's a stitch in there or a couple stitches 372 00:18:30,920 --> 00:18:32,280 and it's going to shave down the prominent bone. 373 00:18:32,280 --> 00:18:34,440 And we usually do a two week follow up whenever there's 374 00:18:34,440 --> 00:18:37,120 stitches and there might be a normal shoes or a surgical shoe 375 00:18:37,120 --> 00:18:40,280 after that example of a foreign body removal. 376 00:18:41,440 --> 00:18:45,720 Once again this is if there's a non infected one such as like 377 00:18:45,720 --> 00:18:49,000 glass can be hair, a little Pebble, a needle. 378 00:18:49,560 --> 00:18:51,640 You may or may not need anesthesia depending. 379 00:18:52,480 --> 00:18:54,600 Consider anaesthesia with epinephrine so you can see it 380 00:18:54,600 --> 00:18:56,040 better. I tend to use we're getting 381 00:18:56,040 --> 00:18:57,720 X-rays once again like a metallic marker. 382 00:18:57,720 --> 00:18:59,480 You put a metallic marker because you can see if there's 383 00:18:59,480 --> 00:19:02,400 anything underneath there. A lot of times you can't see it 384 00:19:02,400 --> 00:19:05,360 with an X-ray so you may have to do an ultrasound to help you see 385 00:19:05,360 --> 00:19:07,400 better and then tends to be a two week follow up. 386 00:19:07,520 --> 00:19:10,120 If there's an infection you would use an antibiotic. 387 00:19:12,240 --> 00:19:16,080 This is an infected foreign body or just an Abscess. 388 00:19:16,560 --> 00:19:18,280 This tends to be a little bit more difficult. 389 00:19:18,280 --> 00:19:21,400 You would have to open it up with an incision, so you'd have 390 00:19:21,400 --> 00:19:24,240 to numb that up as well. You would flush it out and you 391 00:19:24,240 --> 00:19:25,800 would give patients an antibiotic. 392 00:19:25,800 --> 00:19:27,680 Many times we would take a culture as well. 393 00:19:28,480 --> 00:19:30,480 If we can't get all of it or if we want to know what type of 394 00:19:30,480 --> 00:19:32,880 antibiotic to guide that, if it's large or deep, you would 395 00:19:32,920 --> 00:19:36,200 put them in a surgical shoe and then you would use the the post 396 00:19:36,200 --> 00:19:42,440 op kit afterwards. Fracture Care is is just a 397 00:19:42,480 --> 00:19:45,120 tight, it's more of a billing thing, but when we see someone 398 00:19:45,120 --> 00:19:48,520 with a with a fracture you can do this. 399 00:19:51,240 --> 00:19:56,280 So with fracture Care it's, it's more of a billing issue. 400 00:19:56,280 --> 00:19:58,480 So if there's a fracture in the foot or the metatarsal or 401 00:19:58,480 --> 00:20:01,680 somewhere else, it increases the billing initially. 402 00:20:02,000 --> 00:20:04,760 But then at the follow up visits you don't do office visits, you 403 00:20:04,760 --> 00:20:07,360 only do X-rays unless there's a new condition. 404 00:20:07,360 --> 00:20:10,120 So if we see something like a stress fracture or there's a 405 00:20:10,120 --> 00:20:14,800 fracture many times we'll we'll do this and then we'll do a two 406 00:20:14,800 --> 00:20:16,600 or four week depending for the follow up. 407 00:20:17,320 --> 00:20:19,920 And then if there's like a plantar fasciitis that develops 408 00:20:19,920 --> 00:20:21,080 something else then you could build that. 409 00:20:21,080 --> 00:20:23,960 But normally you're you have a a longer what's called a global 410 00:20:24,040 --> 00:20:28,560 period in between this fracture care hardware removal. 411 00:20:28,560 --> 00:20:30,240 We don't do this that often in the office. 412 00:20:30,480 --> 00:20:32,200 Occasionally we'll take out a a little screw. 413 00:20:32,200 --> 00:20:35,920 We used to do it more, but this is an example of a little screw 414 00:20:35,920 --> 00:20:39,760 and you would do this with an X-ray and you would just put a a 415 00:20:39,760 --> 00:20:41,760 guide wire down there and pull out that screw. 416 00:20:43,040 --> 00:20:45,640 We don't do it all that often. You put a couple of sutures in 417 00:20:45,640 --> 00:20:47,560 there. The most common ones we used to 418 00:20:47,560 --> 00:20:50,840 use were FRS but that tended to strip in the office so it made a 419 00:20:50,840 --> 00:20:52,840 little bit hard. There's osteo Med works a little 420 00:20:52,840 --> 00:20:56,600 bit easier because it has a different head of the of the 421 00:20:56,600 --> 00:20:58,680 screw. So occasionally we'll do that 422 00:20:58,680 --> 00:21:02,920 depending on patient's preference hematoma or incision 423 00:21:02,920 --> 00:21:06,920 and drainage of of of blood underneath the nail, it can be 424 00:21:06,920 --> 00:21:09,800 used to drain this hematoma. Sometimes the nail will come off 425 00:21:10,520 --> 00:21:12,840 and the entire nail can be evolved. 426 00:21:12,840 --> 00:21:16,080 When or evolving a nail, we tend to put some nonstick dressing on 427 00:21:16,080 --> 00:21:19,400 top of it because it really hurts to pull it off if it 428 00:21:19,400 --> 00:21:22,000 sticks on there. And with these we also want to 429 00:21:22,000 --> 00:21:25,280 check many times with an X-ray to see if there's any fracture 430 00:21:26,240 --> 00:21:30,040 amnio injection. So amnio injections are used to 431 00:21:30,040 --> 00:21:33,360 help speed up healing of chronic tissue injury, very similar to 432 00:21:33,360 --> 00:21:37,440 where the shockwave is done, but it can be used in areas that 433 00:21:37,440 --> 00:21:39,920 aren't typical for cortisone. So for example, the plantar 434 00:21:39,920 --> 00:21:42,360 fascia, you can use cortisone, but the Achilles tendon you 435 00:21:42,360 --> 00:21:44,920 can't and so this would be an area you could do it on the 436 00:21:44,920 --> 00:21:49,120 Achilles that's safe. I tend to immobilize the 437 00:21:49,120 --> 00:21:51,560 patients in a walking group for three to five days after I do an 438 00:21:51,560 --> 00:21:55,400 amnio just because it's it's kind of a not because of the 439 00:21:55,480 --> 00:21:58,800 procedure but because it's such an expensive treatment to put 440 00:21:58,800 --> 00:22:01,880 inside there. And I I typically use in 441 00:22:01,880 --> 00:22:04,640 conjunction with shockwaves. So not by itself I will do let 442 00:22:04,640 --> 00:22:07,240 us say 3 shockwaves and at the second visit I will do amnio. 443 00:22:08,040 --> 00:22:12,440 Currently we are using right via flow and you can expand it 3 to 444 00:22:12,440 --> 00:22:14,480 1. So what that means is if you 445 00:22:14,480 --> 00:22:16,280 have a, they come in at half CCS. 446 00:22:16,560 --> 00:22:21,760 So you would do half CCS of amnio and then you would do, I 447 00:22:21,760 --> 00:22:26,920 tend to do 1.5 CCS of saline and then a half CC of Marcaine. 448 00:22:27,880 --> 00:22:30,680 OK. So it expands into two CC's 449 00:22:30,680 --> 00:22:32,240 total or about. Yeah. 450 00:22:32,440 --> 00:22:35,160 So I think it's one CC, Yeah, one CC is saline and half and a 451 00:22:35,160 --> 00:22:38,480 half CC of Markane for a little bit of numbing in there. 452 00:22:38,960 --> 00:22:41,800 The way I word it to patients is I say it helps stimulate your 453 00:22:41,800 --> 00:22:44,520 own stem cells to speed up healing and it's safer than 454 00:22:44,520 --> 00:22:47,080 cortisone. That's kind of how I, I word it. 455 00:22:47,080 --> 00:22:51,360 To the to the patients and meditations, they just they want 456 00:22:51,360 --> 00:22:53,520 what's best, right. That's what our patients 457 00:22:53,520 --> 00:22:55,560 sometimes want. And so we can we can offer that 458 00:22:55,560 --> 00:23:00,320 we can offer Shockwave and and the amnio as well cortisone 459 00:23:00,320 --> 00:23:02,160 injections. We still use cortisone. 460 00:23:02,800 --> 00:23:06,960 It can be used for fascia tendon joints usually between 1:00 and 461 00:23:06,960 --> 00:23:10,640 3:00 CCS. We pre drop here in the office 3 462 00:23:10,640 --> 00:23:14,000 CCS for for our patients in case we need it. 463 00:23:14,600 --> 00:23:16,480 You might not have to use the whole thing like in certain 464 00:23:16,480 --> 00:23:18,280 joints that are smaller you can't use the whole thing. 465 00:23:19,400 --> 00:23:22,280 Sometimes patients can develop it called a steroid flare 466 00:23:22,800 --> 00:23:24,720 reaction and I always tell them about that. 467 00:23:24,720 --> 00:23:26,720 It might get red, it might get swollen because it's a formed 468 00:23:26,720 --> 00:23:28,480 substance in your body that you're not used to. 469 00:23:29,720 --> 00:23:31,760 It's very effective for patients that have a gout flare up. 470 00:23:31,800 --> 00:23:33,960 Be careful if there's any signs of infection though. 471 00:23:34,280 --> 00:23:40,080 It's not typically done in the Achilles region and it's and 472 00:23:40,080 --> 00:23:42,440 also we don't usually use it and the MPJS. 473 00:23:42,440 --> 00:23:46,600 So 1st and 2nd MPJ, third MPJ because it can cause weakening 474 00:23:46,600 --> 00:23:49,560 of the tissue and like hammer toe formation, sometimes I will 475 00:23:49,560 --> 00:23:54,320 do it if if I put them in a walking boot or if I just warn 476 00:23:54,320 --> 00:23:55,760 them and there's nothing else that they want. 477 00:23:55,760 --> 00:23:58,640 They don't want anything else or if they've tried other things, 478 00:23:59,680 --> 00:24:01,840 just be really careful you're going to because you could cause 479 00:24:01,840 --> 00:24:04,560 weakening or hammer toe or plantar plate tear or things 480 00:24:04,560 --> 00:24:06,440 like that. It's commonly done with 481 00:24:06,440 --> 00:24:10,560 ultrasound guidance and in our hands. 482 00:24:10,560 --> 00:24:12,960 Now in the office we tend to do less cortisone because we have 483 00:24:12,960 --> 00:24:16,120 the shockwave treatment and we tend not. 484 00:24:16,120 --> 00:24:18,880 Every patients always ask this how many, how many injections 485 00:24:18,880 --> 00:24:21,840 can I have? We tend to do no more than three 486 00:24:21,840 --> 00:24:24,000 injections in any location per year. 487 00:24:24,000 --> 00:24:25,880 So they can have three in the knee, three in the back, three 488 00:24:25,880 --> 00:24:28,720 in the foot, like 3 in the heel, three in the big toe joint. 489 00:24:28,720 --> 00:24:31,240 They can have three anywhere. Sometimes you can do more, but 490 00:24:31,240 --> 00:24:33,320 you just have to be careful if you do too many of them. 491 00:24:34,440 --> 00:24:38,320 Another area that we inject with cortisone is the neuroma and you 492 00:24:38,320 --> 00:24:41,680 evaluate for the molder sign. That's just where you squish the 493 00:24:41,680 --> 00:24:43,280 foot and it causes a clicking motion. 494 00:24:43,520 --> 00:24:47,280 Patients tend to say they have a a fullness feeling or they're 495 00:24:47,280 --> 00:24:52,000 walking on a bunched up sock. Injection can be done with an 496 00:24:52,000 --> 00:24:56,680 ultrasound and then you kind of inject that area, that little 497 00:24:56,680 --> 00:25:00,680 bulb that you can see right here, two to three CC's of 498 00:25:00,680 --> 00:25:02,480 cortisone. If you're doing an ultrasound 499 00:25:02,480 --> 00:25:04,960 you tend not to use as much because you can get it directly 500 00:25:04,960 --> 00:25:07,960 into the area. So we say like a drop is the 501 00:25:07,960 --> 00:25:10,360 same as a gallon, if you can get it in the right spot you don't 502 00:25:10,360 --> 00:25:13,000 need as much and we tend to do a two week follow up for these 503 00:25:13,000 --> 00:25:15,760 neuroma injections, other tendons that can be injected as 504 00:25:15,760 --> 00:25:17,560 well. This is an example at the base 505 00:25:17,560 --> 00:25:20,280 of the fifth metatarsal where the injection or the insertion 506 00:25:20,280 --> 00:25:23,240 of the Pronius Brevis is. This is an ultrasound, you can 507 00:25:23,240 --> 00:25:26,120 see the inflammation. It can be done in any painful 508 00:25:26,120 --> 00:25:27,880 tendon, but once again you have to be careful for tendon 509 00:25:27,880 --> 00:25:29,920 weakening. You might want to immobilize 510 00:25:29,920 --> 00:25:33,440 them in a walking boot or place an UNA boot around the area to 511 00:25:33,440 --> 00:25:37,080 rest it and typically done with ultrasound to see the area of 512 00:25:37,080 --> 00:25:40,440 damaged tissue and you have to discuss the risks of rupture. 513 00:25:40,560 --> 00:25:43,080 And also the other option would be the shockwave which we tend 514 00:25:43,080 --> 00:25:46,640 to do more so now than the cortisone. 515 00:25:48,040 --> 00:25:50,000 Things that we don't do that often, but I just want to talk 516 00:25:50,480 --> 00:25:52,920 quickly about injection of scars. 517 00:25:52,920 --> 00:25:54,920 So some patients come in with really painful scars. 518 00:25:55,240 --> 00:25:59,440 We can inject those painful or keloid scars with cortisone. 519 00:26:00,240 --> 00:26:02,320 Don't do it all that much. There are other things that you 520 00:26:02,320 --> 00:26:08,600 can use like silicone tape, something called skarguard and 521 00:26:08,600 --> 00:26:10,760 other treatments include laser treatment which we'll talk about 522 00:26:10,760 --> 00:26:13,640 a little bit later that can reduce the thickness and the the 523 00:26:13,640 --> 00:26:17,200 color in the area. And I kind of think of scars 524 00:26:17,200 --> 00:26:20,360 similar to a plantar fibromas which are those big lumps in the 525 00:26:20,360 --> 00:26:22,640 bottom of the foot. They're kind of treated the same 526 00:26:22,640 --> 00:26:25,440 way because they're proliferation of tissue 527 00:26:26,760 --> 00:26:31,040 keratomas or just callousing. We trim them with A-15 blade. 528 00:26:32,480 --> 00:26:35,640 If there's bleeding underneath it, you have to be aware because 529 00:26:35,640 --> 00:26:40,280 normally the bleeding makes it an ulcer, so that would be it. 530 00:26:40,280 --> 00:26:43,720 And be careful between the toes. You could also have issues and 531 00:26:43,720 --> 00:26:46,200 recommend We tend to recommend a callus cream and a pumice, so 532 00:26:46,200 --> 00:26:48,600 patients are going to pumice in the shower and then use the 533 00:26:48,600 --> 00:26:50,240 callus cream after one with padding. 534 00:26:50,520 --> 00:26:52,600 And many times they'll do orthotics and things like that. 535 00:26:52,600 --> 00:26:56,440 And if there's fissure fissures skin, we'll use sleep and heel. 536 00:26:56,440 --> 00:26:58,840 So fissures are on the back. We'll use that sleep and heel 537 00:26:58,880 --> 00:27:01,120 callus cream and other things like that.