I want to talk a little about using shockwave for nerve pain.
Shockwave isn't something that I started out using for nerves.
It's when you're starting out, it's easier to to use for
plantar fasciitis, for Achilles tendonitis, for other types of
like 4 foot pain, things like that.
After you do that, that I found it was easier to use focus
shockwave for, for fractures for example, works well.
And now as I've been having it do using it a little bit longer,
I'm using it on nerve. So yesterday I, I did 2 neuromas
that someone had in their forefoot where they're having
pain. So I, I used a dorsal approach.
I used to focus shockwave very low energy like .05.
And then today I had an interesting patient.
She's a 67 year old female. She came in and she had dorsal,
the intermediate dorsal cutaneous nerve pain.
So with palpation she had had, this is her second MRI and it
showed a little bit of scar tissue in that area.
I think she had a previous ganglion that popped and there's
some kind of scar tissue. So we did radial all around the
dorsal midfoot ankle region and then did a shockwave focused
really low energy. I'm going to start with three.
So I'm going to explain a little bit about my my protocol in
terms of how it's changed over time.
With Shockwave, I used to do 3 sessions, then do a six week
follow up and then do another three sessions.
I did a little bit of coaching with Paul Habro and he
recommended and I do find this, it's nice to do 6 sessions now
because usually about the 5th week is where people start to
find an improvement. So I'm I'm present now when,
when patients are actually getting better and it's nice to
be there when they're when they're going around the corner.
What I used to do is when I send them to physical therapy.
These are getting better at physical therapy.
So my joke is that physical therapy got all the credit so
that that is some just some kind of adaptations of how I'm using
shockwave at this time. Next patient was a 72 year old
man. He had a post up post op
bunionectomy with a hammer toe repair.
He asked me to do his nails so I did nails his.
His bunion was still within the global period.
You know, one of the benefits of of Mod Med that we switched to
is it it's really good at tracking global periods for
surgical procedures for let's say routine nail care.
So I think the billing component of Mod Med is, is quite superior
as I'm kind of getting deeper into it as compared to Athena.
He does also have some self paid callus.
So he paid 75 for the callus. I did the nail to Bryman and
then just the post op we got the X-rays.
Next was 80 year old female. She had a left fourth met stress
fracture. So this one was a fracture code.
She did a Cam boot and I'm going to see her back in four weeks.
Next was a 49 year old female. She had a left.
This one had a fourth met fracture.
It's been about four months. It's it's not healed.
OK. And so for this one, we are
going to do shockwave. So I set up for focused only
shockwave. I, I tend to do when I'm doing
fracture care, I'm tending to do 4 shock waves When I'm doing
like soft tissue care, like plantar fasciitis, Achilles,
things like that, I'm doing 6. So I did 4 focused only.
So that was a good, that was a good patient because she did not
respond to the other, other treatments.
Next was a 70 year old for bilateral plantar fasciitis.
So bilateral sessions, this is number 2 out of 6 for shockwave.
Starting to get a little bit better.
Next was a 63 year old female for left arthritis midfoot, did
ultrasound guided cortisone injection.
So basically with ultrasound I go to the midfoot, follow the
metatarsals back to the met cuneiform or nvicular cuneiform
joints, whatever one is arthritic or they're swelling
around that you can see usually spurring on the ultrasound that
I do. I drop a little cortisone, I try
to do like 1 CC in each of the joints that are painful for this
patient. I did an X-ray for her as well.
Now this patient also has a feeling of the legs feel like
wood and I tend to when they my patients say leg feels like
wood. I think of neuropathy and this
patient already is being treated by another provider.
I don't focus too much on neuropathy.
This is a non diabetic kind of like a back pain type of
neuropathy. Next was a a 80 year old female.
She had a left and her left foot.
She had pincer nails 1-2 and five and they were thickened as
well. So she was concerned about,
well, you know, should I treat my nail fungus and, and AT80I,
I, I have to look at these. And she was a, a very, you know,
well kept 80 year old. And I said, you know, if you're
my, I said mom, But then I thought, if you're my grandma, I
would, I wouldn't treat them. I would just come in and either
have me trim the nails or go to a nail salon to trim the nails.
She also in the past she had a flexor tonotomy on the 4th toe
and she was asking me, hey doc, why in the world did you even do
that? And I think patients, they
forget why we why we do things and what was hurting her.
I said, do you remember you had a really bad callus at the tip
or I think it was an ulcer at the tip of the toe and that's
why we did the flexor tonotomy and it's looking great.
That one we did in the office. That's one of my favorite
procedures to do is a flexor tonotomy with a 18 gauge needle.
Next was a 39 year old female. She had a right partial nail
evulsion. She had a painful ingrown
toenail on one side on the right foot on the side of that nail
that was kind of chronic. And then on the left side she
had, she was concerned with nail fungus.
And I and I reassured her, you know, that she was from the
Cameroon. She was a very tall patient with
big feet, like a size 12 for a female and, and, and I said, Are
you sure your shoes are big enough?
And she came in a sandal. So I couldn't really show her
that. But what I tend to do in the
practice is I, I take my, my, my, my sock, my shoes off
actually. And I and I take out my sock
liner and I usually wear lems in the office and in the, in the
lems I show them like the indentation of my toes.
There's about a fingers breath where the indentation of my big
toe is and the front of the sock liner.
And I and I just tell them, I say what I'd like you to do is
I'd like you to take out the sock liner in your shoe.
And if your toes go right to the tip of the liner, it's probably
too small and that could be causing some of the toenail pain
or toenail changes that you're having.
So that's a real easy test. I call that the the sock liner
test that I do with my patients. Next was a 33 year old female.
She made an urgent care appointment for a possible
fracture of her 5th metatarsal base.
Now this was 1 I did a video on because I'm trying to get more
urgent care patients and this is a prime one.
She went there, she got crutches, she got a Cam boot.
And when I looked at the X-ray, she she got to do X-rays.
She had a little like an ossicle at the fifth met base and there
was no pain, there's no swelling.
And this was one that she could have saved a lot of Rev money
coming to see us. So I did a little video and I'm
going to put that on our urgent care page.
Just so you know, the urgent care page seems to be working
well. We have patients come in every
day and the nice thing on my schedule, it says urgent care.
So I can see if they've actually come from from that.
Next patient was a 54 year old female for left second and third
met met cuneiform arthritis and she also had some sinus tarsi
pain and she she wasn't really interested in doing cortisone.
She actually wanted orthotics. So I scanned her for orthotics
that was orthotic #1 and I'm going to see her back in
basically about two months. So with orthotics, what I do is
I, I see them back in three weeks for my staff does to pick
them up and they get my little, they get little piece of paper
with the offering the second pair of orthotics and the break
in schedule and then I see them six weeks after that.
Next patient was a 58 year old man.
He had left shark coat and he was going to be getting a crow
boot from one of my other colleagues and for some reason
he ended up on my schedule. He had a right second toe ulcer
and I had to bride at that. That was the morning afternoon.
There's a 43 year old female with left tibialis anterior pain
at the insertion. She's #4 out of 6 for Shockwave.
She brought in her little boy who I showed magic tricks.
Just so you know when when little kids come in, I tend to
show them magic tricks. If you want to see any of my
magic tricks, just ask me. My favorite 1 is where I take a
piece of gauze and I get close to them and I, and I ask them
what hands it and I kind of kind of move my hand and say is it
the right or the left? And then I do it a couple times
and the last time I throw it right over their head and, and
they don't know that. And then I make it disappear.
But the problem is at the end of the day, I have a whole bunch of
gauze in the back of my, behind my, my chairs in my office.
OK, so she is doing much better. She's already pleased.
She's back to walking, running. She's #4 out of 6 for this.
And this has been going on for her for over a year.
So she's getting better faster. Next was a 61 year old man who
had a right nail damage and I took a nail sample.
I don't think it is a fungus. He is super paranoid.
So I mostly just talked this patient off the Cliff.
He was a cash pay patient. He had mass health, which we
don't take in our office and he opted for for seeing us to, to
do this nail sample. I sent out to pathology for
evaluation. But I, I really don't think it
is. I think he's a little
overzealous here, worried about his feet.
Next was a 72 year old man, did a diabetic foot exam.
He had some maceration, so I kind of used tineopedus as the
diagnosis for that diabetic foot exam.
When I do those foot exams, I try not to use diabetes.
I try to pick what other type of pathology that they have.
Next was a 70 year old female and this patient had really bad
Aquinus really tight and so I did my Pelto special which is a
night splint foam rolling in morning stretch and they had a
little bit of FHL pain so proximal to the first met head
and also just some lateral foot pain and all due to that that
tightness that was the main issue.
Next was a 59 year old female. She had a a right second toe
with blood underneath it and she was concerned of certainly a
Melanoma. I was able to trim back the
toenail and just show her that it was dried blood and she also
so just kind of calmed her down and she also had some
superficial article mycosis on both great toenails, mostly from
taking off her nail Polish. So I explained about how to
buffer that down. I'm not going to see her back.
Next was a 21 year old female. She's status post a fibula
fracture. She's still having pain to the
sinus tarsi and to the lateral tailored Dome region.
So I'm going to order an MRI for her.
Next was a 59 year old man for #4 out of 6 for plantar
fasciitis. Next one I'm not going to go in
or I'm just going to do all the shockwave here.
Next was a 33 year old man for #2 out of 6 for plantar
fasciitis for the right. And then there was a 47 year old
man. He had bilateral Achilles
insertional. He's #3 out of 3 for shockwave.
So let me explain why he's only three out of three.
It's the reason. It's the reason.
The reason is, is because a few years ago he had shockwave and
he had three sessions. So I, I find a lot of times what
patients want to do is what they did last time.
I think they even call this, we had a, we had a recent
conference here in Massachusetts.
And I think it's, I think it's O'leary's law or Malley's law.
Basically, if you did something one way for a patient in the
past, let's say they had a McBride bunion like 30 years
ago, do a McBride, do a McBride today or do, do like whatever
the same procedure they had last time, do it this time because
that's what they want, because that's what they know.
So he had three sessions before, mostly I do 6 now, but I only
did 3 because of that. So and just a reminder, every
time I do my last shockwave session, I do an office visit
because I'm going to talk about what's next for the patient.
So whenever I'm doing 3, the last visit will do a Level 3
office visit. And then if I'm doing 6, the
last session I'm doing an office.
So usually, let's say the first visit I'm evaluating and I do
shockwave the first time. So I'll do an office visit and
then the last time I'll do an I'll do an office visit for
them. The ones in between, I don't do
an office visit every single time.
I know there are some people that, oh, I can do an office
visit every time. I don't think I'm really
changing my evaluation and management.
And the last patient was actually my MVP patient of the
day. This was a MVP's most valuable
patient. So let me explain this patient.
He had a right. He was.
So first of all, I tend to find my, my, some of my best patients
are referred for mothers. So he came from another family
member, a 51 year old man with right cave, his foot very high
cave, his foot that kind of almost like pronates a little
bit even despite being The Cave is.
So he's overloading on the lateral foot, has lateral kind
of calluses on the right foot, and he has four foot calluses on
the left foot. He has a severe Aquinas, which I
think is causing a lot of that lateral foot pain that he's
having. So I did an orthotic for him and
since he has bilateral Aquinas, I did bilateral night splints.
He's going to do foam rolling in the morning stretch.
And so because of the bilateral light splints and he also got
scanned for orthotics. That's why he was considered my
my most valuable patient. So that was that was the day.
For those that are listening, I am working on putting together a
six month challenge that you bet you should be seeing some emails
coming out. If you don't get my emails, you
can go to podiatrypracticemastery.com and
sign up for anything that I have as a free download there and
you'll get those emails. But we're putting together a six
month challenges for people that wanted to get to their practice
over the $1,000,000 mark. And it's going to be a little
bit better for those that are around the 6 to 700,000.
That's how much you're producing in a year.
Trying to get that to the million or past the $1,000,000
mark a little bit harder when you're just starting out because
your, your main focus is going to be on marketing and producing
content and stuff like that. Wanted to share a kind of a neat
little tip I learned recently. I was like to share new tips.
I was talking to a gentleman and I've been doing my these
podcasts for a while and I'm not getting much traction on
LinkedIn with these and I'm not sure why.
So if you like this podcast and you listen to it, please just go
wherever you're listening and review it.
I think that would help me. But in terms of LinkedIn, I send
the post every day and I know probably a lot of, but I just
never looked at LinkedIn because we're all way too busy.
But what he recommended is doing some just regular posts on
LinkedIn and not doing just links because if you do a link
to like a podcast, a lot of times they, they don't show it
to as many people. So I'm, I've been doing that
and, and the easiest way is this podcast I, I record on my phone.
So I have a little transcript and then I just take the so on
your recording set with the new iPhone now it transcribes
everything. I just put that in chat sheet BT
on my phone and it gives me like 3 LinkedIn like ideas or three
LinkedIn like topics. So I'm going to post those in
the description. So if you want to see what those
are just so you can get an idea. And then I then I post that on
LinkedIn. So it kind of gives some high
highlight ideas of the episode. Anyway, those are the things I'm
working on. We'll talk more tomorrow.
Thanks.